What are the indications and benefits of carotid endarterectomy over carotid stenting in patients with carotid artery stenosis?

Carotid Endarterectomy: Indications and Benefits Over Stenting

Carotid endarterectomy (CEA) is the preferred revascularization procedure for most patients with carotid artery stenosis, particularly those over age 70, and should be performed urgently within 2 weeks for symptomatic high-grade stenosis. 1

Indications for Carotid Endarterectomy

Symptomatic Carotid Stenosis (Strongest Indication)

For patients with recent TIA or non-disabling stroke:

• 70-99% stenosis: CEA is mandatory and should be performed urgently, ideally within the first few days and no later than 14 days after the ischemic event 1
• 50-69% stenosis: CEA provides moderate benefit with an absolute risk reduction of 4.6% at 5 years, though the benefit is smaller than with severe stenosis 2, 3
• <50% stenosis: CEA is not indicated as patients do not benefit from surgery 2, 3

The perioperative stroke/death rate must be <6% for symptomatic patients to maintain favorable benefit-risk ratio 1, 2

Asymptomatic Carotid Stenosis (More Controversial)

For patients with 60-99% asymptomatic stenosis:

• CEA may be considered only if perioperative stroke/death rate is <3% 1, 2
• The benefit is substantially smaller than for symptomatic patients—83 patients must be treated to prevent one stroke in 2 years 4
• Patient must have life expectancy >5 years to realize benefit 1
• The absolute risk reduction is approximately 1% per year (from 2% to 1% annual stroke risk) 1

CEA Benefits Over Carotid Artery Stenting (CAS)

Age-Related Superiority

CEA is definitively superior to CAS in patients over age 70: 1

• In octogenarians, stroke risk is 1% for CEA versus 3% for CAS 1
• Current evidence demonstrates CAS carries higher periprocedural stroke and death rates in older patients 1

Procedural Outcome Differences

CEA demonstrates better periprocedural stroke outcomes:

• Nationwide data shows in-hospital stroke rate for asymptomatic patients undergoing CAS was 2-fold higher than CEA 1
• CEA mortality rate: 0.44%; stroke rate: 0.95% in large registry data 1
• CEA is particularly preferred for patients with calcified plaques 5

CEA provides superior long-term durability:

• Freedom from occlusion and restenosis ≥70% at 12 years: 98.8% 6
• Late occlusion rate: 0.6%; recurrent stenosis ≥70%: 0.5% 6

Complication Profile Differences

CEA has lower stroke risk but different non-stroke complications:

• CAS associated with higher periprocedural stroke rates, particularly in older patients 1
• CEA associated with higher rates of myocardial infarction, cranial nerve injury, neck hematoma, and wound complications 1
• However, the primary outcome of stroke prevention favors CEA in most patient populations 1

When CAS May Be Considered Over CEA

CAS is appropriate only for specific high-risk surgical candidates: 1

• Contralateral laryngeal nerve palsy
• Previous radical neck surgery or radiation therapy to the neck
• Recurrent stenosis after prior endarterectomy
• Severe cardiac or pulmonary disease making general anesthesia prohibitively risky
• Anatomically inaccessible lesions (very high or very low in neck)

Even in these high-risk patients, CAS must be performed by experienced operators with documented perioperative stroke/death rates <5% 1

Critical Quality Benchmarks

Surgeon/center performance requirements:

• Symptomatic patients: Combined perioperative stroke and death rate must be <6% 1
• Asymptomatic patients: Combined perioperative stroke and death rate must be <3% 1, 2
• Centers must routinely audit their performance results 1

Evidence Base Comparison

The CREST trial (2010) showed no significant difference in composite outcomes between CEA and CAS in asymptomatic patients (p=0.15), but this included younger patients where CAS performs better 1

The SAPPHIRE trial enrolled only high-risk surgical candidates and showed similar outcomes, but this does not apply to standard-risk patients 1

Pooled data from three major trials for symptomatic severe stenosis (70-99%) demonstrated CEA provides 16% absolute risk reduction at 5 years compared to medical management alone (NNT=6) 1

Common Pitfalls to Avoid

• Do not delay CEA in symptomatic patients—benefit is greatest when performed within first few days, and diminishes significantly after 2 weeks 1
• Do not perform CEA for <50% symptomatic stenosis—these patients do not benefit and may be harmed 2, 3
• Do not use CAS routinely in patients >70 years when they are otherwise fit for surgery 1
• Do not proceed with CEA if your center's complication rates exceed guideline thresholds—the benefit disappears with higher complication rates 1, 2
• Do not assume improved medical management eliminates need for CEA in high-grade symptomatic stenosis—surgery still provides significant benefit even with optimal medical therapy 5

Perioperative Medical Management

All patients undergoing CEA require:

• Low-dose aspirin 81-325 mg daily (preferred over higher doses 650-1300 mg) to reduce stroke, MI, and death 2
• Continuation of intensive medical therapy including statins, antihypertensives, and diabetes control 5
• These medications should be continued indefinitely post-procedure 5