What is the role of carotid endarterectomy (CEA) in managing carotid artery stenosis in patients with a history of transient ischemic attacks (TIAs) or strokes, particularly in older adults with vascular disease risk factors?

Carotid Endarterectomy (CEA) for Stroke Prevention

CEA is strongly recommended for patients with recent TIA or nondisabling stroke (within 6 months) who have ipsilateral severe (70-99%) carotid stenosis, provided the perioperative stroke/death risk is <6%, with an absolute risk reduction of 16% over 5 years. 1

Indications Based on Stenosis Severity

Severe Stenosis (70-99%)

• CEA is the gold standard for symptomatic severe stenosis, providing robust benefit with 16% absolute risk reduction over 5 years compared to medical therapy alone 1, 2
• The procedure must be performed by operators with documented perioperative morbidity and mortality rates <6% 1
• Surgery should ideally be performed within 2 weeks of the index event rather than delaying, as this increases the likelihood of stroke-free outcomes 1

Moderate Stenosis (50-69%)

• CEA is recommended but with more nuanced decision-making based on patient-specific factors including age, sex, and comorbidities 1
• The absolute benefit is lower (4.6% absolute risk reduction at 5 years) compared to severe stenosis 3
• The perioperative risk threshold remains <6% 1

Mild Stenosis (<50%)

• CEA is not recommended and provides no benefit for stroke prevention 1
• Medical therapy alone is the appropriate management 1

Age Considerations in Older Adults

For patients ≥70 years of age, CEA is preferred over carotid artery stenting (CAS) to reduce periprocedural stroke rates. 1

• Older adults have significantly lower periprocedural stroke risk with CEA (1%) compared to CAS (3%) 4
• Age >70 years is a relative contraindication to stenting, making CEA the definitive choice in this population 4

Timing of Surgery

Early revascularization within 2 weeks is reasonable and preferred over delayed surgery. 1

• For patients with TIA or minor stroke, there is no need for time-delay; surgery can proceed promptly 3
• If revascularization is planned within 1 week of the index stroke, CEA should be chosen over CAS to reduce periprocedural stroke rates 1
• Patients with more extensive strokes or hemorrhagic transformation should wait 4-6 weeks before surgery 3

Mandatory Concurrent Medical Therapy

All patients must receive intensive medical therapy regardless of whether they undergo CEA. 1

This includes:

• Antiplatelet therapy (aspirin or clopidogrel) 1
• High-intensity statin therapy for lipid-lowering 1
• Blood pressure control and treatment of hypertension 1
• Risk factor modification including diabetes management and smoking cessation 1, 5

CEA vs. Carotid Artery Stenting (CAS)

CEA is generally preferred over CAS in most symptomatic patients, particularly those ≥70 years and those requiring urgent revascularization. 1

When to Consider CAS Instead of CEA:

• Radiation-induced stenosis or restenosis after previous CEA 1
• Surgically inaccessible lesions or difficult surgical access 4
• Severe medical comorbidities that substantially increase surgical risk 4
• CAS operators must still demonstrate periprocedural stroke/death rates <6% 1, 4

Critical Contraindications and Pitfalls

Complete Carotid Occlusion

• CEA provides no benefit for chronic total occlusion of the internal carotid artery 5
• Medical therapy alone is the only recommended treatment for complete occlusion 5
• EC/IC bypass surgery was also studied and found ineffective 5

Operator Experience Requirements

• The surgeon must have established perioperative stroke and mortality rates <6% for symptomatic patients 1
• Institutions should routinely audit performance results 4
• For asymptomatic stenosis (not the focus here), the threshold is even stricter at <3% 6

Common Pitfall to Avoid

• Do not perform CEA if the perioperative risk exceeds 6%, as this negates the benefit of surgery 1
• Do not delay surgery unnecessarily in stable patients with TIA or minor stroke, as early intervention (within 2 weeks) improves outcomes 1

Evidence Base

The recommendations are based on landmark trials including NASCET (North American Symptomatic Carotid Endarterectomy Trial), ECST (European Carotid Surgery Trial), and VA Trial 309, which collectively demonstrated robust benefit for CEA in symptomatic severe stenosis 1, 2, 7. The combined analysis by Rothwell et al showed 16% absolute benefit over 5 years for patients with 70-99% stenosis 1.