CEA vs CAS in Symptomatic Carotid Stenosis After Stroke/TIA
For patients with symptomatic high-grade carotid stenosis after recent ischemic stroke or TIA, carotid endarterectomy (CEA) is the preferred first-line revascularization over carotid artery stenting (CAS), particularly in patients ≥70 years of age and when intervention occurs within 1 week of the index event. 1
Primary Recommendation: CEA as First-Line
CEA should be performed for symptomatic stenosis ≥70% and is reasonable for stenosis 50-69%. 1 The evidence supporting CEA is robust, with a 16.0% absolute benefit over 5 years in patients with severe (70-99%) stenosis based on combined analysis of landmark trials (NASCET, ECST, VA Trial 309). 1
Critical Timing Considerations
Perform CEA within 2 weeks of the index event, ideally within the first few days, to maximize stroke-free outcomes. 1 The urgency is driven by compelling data:
- When performed within 1 week: CEA has dramatically lower stroke/death rates (1.3%) compared to CAS (8.3%), with a relative risk of 6.7 (P=0.002). 1
- Post hoc analyses demonstrate greater benefit when CEA is performed within 2 weeks of the ischemic event. 1
Age-Based Decision Making
For patients ≥70 years of age, CEA is strongly preferred over CAS to reduce periprocedural stroke risk. 1 The Carotid Stenting Trialists' Collaboration data shows:
- Ages 70-74: Hazard ratio for CAS vs CEA = 2.09 (95% CI, 1.32-3.32) 1
- Ages 65-69: Hazard ratio = 1.61 (95% CI, 0.90-2.88) 1
This means older patients face substantially higher periprocedural stroke risk with CAS. 1
When CAS May Be Considered
CAS may be considered as an alternative only in specific circumstances: 1
- Younger patients (<70 years) with symptomatic ≥50-99% stenosis 2
- High surgical risk conditions: radiation-induced stenosis, restenosis after prior CEA, hostile neck anatomy 1
- Significant cardiovascular comorbidities that increase endarterectomy risk 1
- When anticipated periprocedural stroke/death rate is <6% 1
However, CAS carries only a Class 2b recommendation (Level A evidence), meaning it "may be considered" rather than being strongly recommended. 1
Quality Standards Required
Both procedures must meet strict performance benchmarks: 1
- Combined perioperative stroke and death rates must be <6% 1
- Surgeons/interventionalists must routinely audit their performance results 1
- The randomized trials supporting these recommendations achieved 5-7% combined perioperative stroke/death rates 1
Common Pitfalls to Avoid
Do not delay revascularization beyond 2 weeks in stable patients, as this reduces the likelihood of stroke-free outcomes. 1 However, patients who are clinically unstable in the first few days should be stabilized before proceeding. 1
Do not perform revascularization for stenosis <50%, as this provides no benefit and is not recommended (Class III, Level A). 1
Do not choose CAS over CEA in elderly patients (≥70 years) unless there are compelling contraindications to surgery, given the substantially higher periprocedural stroke risk. 1
Measurement and Imaging
Carotid stenosis should ideally be measured by CTA to guide surgical decision-making. 1 The NASCET method of stenosis measurement is the standard, though modern practice typically uses noninvasive imaging rather than the angiography used in original trials. 1
Evidence Quality Considerations
The recommendations favoring CEA are based on high-quality evidence (Level A and B-R) from multiple randomized controlled trials and meta-analyses. 1 The European Stroke Organisation guidelines (2021) similarly recommend CEA for symptomatic stenosis ≥70% and suggest it for 50-69% stenosis, with early intervention within two weeks. 2
Note: Recent CREST-2 trial data (2025) showed benefit for revascularization in asymptomatic stenosis, but the question specifically addresses symptomatic patients where CEA remains the gold standard. 3