What is the stroke risk after a recent carotid endarterectomy (CEA) and how long does the elevated risk persist?

Stroke Risk After Fresh Carotid Endarterectomy

The perioperative stroke risk after carotid endarterectomy is 1.4–3.1% within the first 30 days, with the highest risk concentrated in the immediate postoperative period and declining substantially thereafter. 1

Perioperative Risk Window (0–30 Days)

The elevated stroke risk is confined primarily to the first 30 days after CEA, which defines the "perioperative period" in all major guidelines and trials 1:

• For asymptomatic patients: The 30-day combined stroke and death rate ranges from 1.35% to 3.1% across contemporary registries and trials 1
• For symptomatic patients: The 30-day risk is higher at 2.3% to 7.1%, depending on patient selection and surgical expertise 1
• Approximately 21% of perioperative events occur on or after the day of hospital discharge, emphasizing that the risk extends beyond the immediate hospitalization 2

Timing of Peak Risk

The stroke risk is highest in the first few days after surgery, then declines rapidly 3, 4:

• Most perioperative strokes occur within the first 72 hours postoperatively 4
• The risk remains elevated but progressively diminishes throughout the 30-day window 1, 2
• After 30 days, the stroke risk returns to baseline levels of approximately 1–2% per year, similar to medically managed patients 1

Duration of Elevated Risk

The clinically significant elevated risk period lasts exactly 30 days 1:

• All major trials (ACAS, ACST, CREST) define perioperative complications as events occurring within 30 days of the procedure 1
• Beyond 30 days, the ipsilateral stroke rate in CEA patients is 1–2% per year, which represents the natural history of treated carotid disease rather than a surgical complication 1
• The 5-year post-procedural stroke risk (excluding the 30-day perioperative period) is 3.8% in CEA patients versus 11% in medically managed patients, demonstrating that CEA provides long-term protection rather than ongoing risk 5

Factors That Modify Perioperative Risk

Several factors increase the 30-day stroke risk 3, 4, 2:

• Urgent or emergent surgery increases risk 2.5-fold compared to elective procedures 3
• Longer operative time (each additional 15 minutes increases odds ratio by 1.08) 3
• Concomitant procedures (especially proximal endovascular intervention, which increases risk 8.7-fold) 3
• Elevated baseline diastolic blood pressure (each 10 mmHg increase raises risk by 30%) 2
• Female sex nearly doubles perioperative risk (RR 1.98) 2
• Left-sided surgery is associated with 4.78 times higher stroke risk 4

Clinical Implications for Post-CEA Management

Patients require close neurological monitoring for 30 days after CEA, with particular vigilance in the first 72 hours 4, 2:

• Blood pressure control is critical in the immediate postoperative period to prevent hyperperfusion syndrome 2
• Neurological assessment should continue through hospital discharge and the first outpatient follow-up 2
• After 30 days, the patient's stroke risk profile reflects their underlying atherosclerotic disease burden rather than surgical complications 1, 5

Common Pitfall to Avoid

Do not confuse the 30-day perioperative risk with the long-term stroke risk after CEA. The perioperative risk is a one-time hazard that must be weighed against the long-term benefit of stroke prevention. After surviving the 30-day perioperative window, CEA patients have substantially lower stroke rates than medically managed patients (3.8% vs 11% at 5 years) 5.