From the Guidelines
A carotid endarterectomy is indicated for patients with significant carotid artery stenosis to reduce stroke risk, particularly for symptomatic patients with stenosis of 50-99% who have experienced a transient ischemic attack (TIA) or non-disabling stroke within the past 6 months, as supported by the most recent guidelines 1.
Indications for Carotid Endarterectomy
The decision to perform a carotid endarterectomy is based on the degree of stenosis, symptoms, and patient-specific factors.
- For symptomatic patients with stenosis of 70-99%, carotid endarterectomy is recommended if the morbidity/mortality risk of the surgical team is < 6% 1.
- For symptomatic patients with stenosis of 50-69%, carotid endarterectomy may be considered depending on individual characteristics, including age, sex, and comorbidities, if the morbidity/mortality risk of the surgical team is < 6% 1.
- Asymptomatic patients with stenosis exceeding 60-70% may be considered for surgery, particularly if they have a life expectancy of at least 5 years and are good surgical candidates 1.
Timing and Procedure
- Carotid endarterectomy, if indicated, should be performed as early as possible if the patient is clinically stable, ideally within 14 days after symptom onset 1.
- The procedure is preferred over carotid stenting, but stenting may be considered for patients who are not candidates for endarterectomy due to technical, anatomic, or medical reasons 1.
Preoperative Considerations
Before recommending endarterectomy, physicians should ensure optimal medical therapy is in place, including antiplatelet agents, statins, blood pressure control, and lifestyle modifications 1. The perioperative stroke and death risk should be less than 3% for asymptomatic patients and less than 6% for symptomatic patients to justify the procedure 1.
From the Research
Indications for Carotid Endarterectomy
- Carotid endarterectomy is indicated in symptomatic patients with carotid-territory transient ischemic attacks or minor strokes who have carotid artery stenosis of 70 to 99 percent 2.
- The procedure provides modest benefit in symptomatic patients with carotid artery stenosis of 50 to 69 percent, with a low surgical risk 2.
- In asymptomatic patients, carotid endarterectomy is beneficial for those with carotid artery stenosis of 60 percent or greater, and whose general health makes them good candidates for elective surgery, provided that the arteriographic and surgical complication rates are low 2.
- Early carotid endarterectomy within 48 hours after transient ischemic attack or stroke in evolution can be performed with an acceptable risk in properly selected symptomatic patients, and may prevent recurrent stroke 3.
- Patients with recently symptomatic high-grade carotid artery stenosis and ipsilateral hemodynamic compromise are at high risk for early disabling stroke, and assessment of the hemodynamic status is recommended after diagnosis to evaluate the need for early endarterectomy 4.
- Urgent carotid endarterectomy, typically performed within 48 hours of initial presentation, is beneficial in carefully selected patients with crescendo transient ischemic attacks 5.
- The current literature suggests a changing paradigm towards early carotid surgery, specifically targeted within 48 hours if the index event is transient ischemic attack, and within 7 days if the index event is stroke 6.
Patient Selection
- Patients with disabling neurologic deficit, cerebral lesions >3 cm in diameter, presence or suspicion of parenchymal hemorrhage, or occlusion of the middle cerebral artery are not candidates for carotid endarterectomy 3.
- Patients with contraindications for surgery may be considered for carotid artery stenting 5.
- The decision to perform carotid endarterectomy should be based on individual patient characteristics, including the degree of stenosis, symptoms, and overall health status 2, 3, 4, 5, 6.