What is the difference between Carotid Endarterectomy (CEA) and Mechanical Thrombectomy (MT)?

From the Guidelines

Endarterectomy is the preferred procedure for patients with significant carotid stenosis (70-99%) who are symptomatic or have had a recent TIA or stroke, due to its association with reduced complication rates compared to mechanical thrombectomy, as supported by the 2021 guideline from the American Heart Association/American Stroke Association 1.

Key Considerations

• Endarterectomy involves surgically removing plaque buildup from the inner lining of an artery, typically the carotid artery in the neck, and is most appropriate for patients with significant carotid stenosis who are symptomatic or have had a recent TIA or stroke.
• Mechanical thrombectomy, on the other hand, is an endovascular procedure used for acute ischemic stroke caused by a large vessel occlusion, and must be performed within 24 hours of stroke onset for optimal outcomes.
• The choice between these procedures depends entirely on the underlying condition, with endarterectomy preferred for chronic plaque buildup in carotid arteries and mechanical thrombectomy for acute large vessel occlusion causing stroke.

Procedure Details

• Endarterectomy typically requires general anesthesia, an incision in the neck, and patients often stay in the hospital for 1-2 days, with recovery taking about 1-2 weeks.
• Patients undergoing endarterectomy are usually prescribed antiplatelet therapy (aspirin 81-325mg daily or clopidogrel 75mg daily) afterward.
• The 2021 guideline from the American Heart Association/American Stroke Association supports a preference for endarterectomy in patients who undergo early revascularization, with a reduced complication rate relative to mechanical thrombectomy 1.

Evidence-Based Recommendations

• The Carotid Stenosis Trialists’ Collaboration evaluated 4138 patients randomly assigned to endarterectomy or mechanical thrombectomy, and found a stroke/death rate of 8.3% with mechanical thrombectomy versus 1.3% with endarterectomy (RR, 6.7; P=0.002) in patients who received the procedure within 1 week of the last symptomatic event 1.
• Post hoc analysis of these trials found a greater benefit of endarterectomy when the surgery was done in patients who were enrolled within 2 weeks of their last non-disabling ischemic event, supporting early endarterectomy as the preferred procedure 1.

From the Research

Endarterectomy vs Mechanical Thrombectomy

• The provided studies do not directly compare endarterectomy and mechanical thrombectomy, but rather focus on the efficacy and safety of mechanical thrombectomy in patients with acute ischemic stroke due to large vessel occlusion 2, 3, 4, 5, 6.
• Mechanical thrombectomy has been shown to be effective in improving outcomes in patients with acute ischemic stroke, with studies demonstrating its potential benefit even in patients with mild neurological symptoms 3, 4.
• The choice of treatment for acute ischemic stroke depends on various factors, including the location and severity of the occlusion, as well as the patient's overall health status 5.
• Carotid stenting and mechanical thrombectomy may be considered for patients with tandem occlusions, but the optimal antithrombotic medication for these patients is still unclear 6.
• Further research is needed to fully understand the benefits and risks of mechanical thrombectomy compared to endarterectomy, as well as to determine the optimal treatment strategies for patients with acute ischemic stroke 2, 3, 4, 5, 6.

Key Findings

• Mechanical thrombectomy has been shown to be effective in improving outcomes in patients with acute ischemic stroke due to large vessel occlusion 3, 4.
• The procedure may be beneficial even in patients with mild neurological symptoms 3, 4.
• Carotid stenting and mechanical thrombectomy may be considered for patients with tandem occlusions, but the optimal antithrombotic medication for these patients is still unclear 6.
• The choice of treatment for acute ischemic stroke depends on various factors, including the location and severity of the occlusion, as well as the patient's overall health status 5.

Treatment Considerations

• Mechanical thrombectomy is a viable treatment option for patients with acute ischemic stroke due to large vessel occlusion 2, 3, 4, 5.
• Carotid stenting and mechanical thrombectomy may be considered for patients with tandem occlusions 6.
• The optimal antithrombotic medication for patients with acute ischemic stroke is still unclear and requires further research 6.