What degree of carotid (carotid artery) stenosis indicates carotid endarterectomy (surgical procedure to remove plaque from the carotid artery)?

From the Guidelines

Carotid endarterectomy is generally indicated for patients with carotid stenosis of 70% or greater in symptomatic patients, and 80% or greater in asymptomatic patients. Symptomatic patients are those who have experienced a stroke, transient ischemic attack (TIA), or amaurosis fugax within the past 6 months related to the stenosed carotid artery. For symptomatic patients with moderate stenosis (50-69%), surgery may also be beneficial, but the decision should be individualized based on patient factors such as age, gender, comorbidities, and surgical risk. The degree of stenosis is typically determined using carotid duplex ultrasonography, with confirmation by CT angiography or MR angiography in some cases. The benefit of surgery is greatest when performed within 2 weeks of symptom onset in symptomatic patients. The rationale for these thresholds is based on the balance between stroke risk reduction and perioperative complications. Higher degrees of stenosis carry greater stroke risk, making surgical intervention more favorable despite the 2-3% risk of perioperative stroke or death associated with the procedure. Medical therapy with antiplatelet agents, statins, blood pressure control, and lifestyle modifications should be implemented regardless of whether surgical intervention is pursued, as supported by guidelines from the American Heart Association and other organizations 1.

Some key points to consider in the management of carotid stenosis include:

• The severity of stenosis is a critical factor in determining the need for surgical intervention, with higher degrees of stenosis associated with greater stroke risk 1.
• Symptomatic patients with moderate stenosis (50-69%) may also benefit from surgery, but the decision should be individualized based on patient factors such as age, gender, comorbidities, and surgical risk 1.
• The benefit of surgery is greatest when performed within 2 weeks of symptom onset in symptomatic patients, highlighting the importance of timely intervention 1.
• Medical therapy with antiplatelet agents, statins, blood pressure control, and lifestyle modifications should be implemented regardless of whether surgical intervention is pursued, as it can significantly reduce the risk of stroke and other cardiovascular events 1.

Overall, the management of carotid stenosis requires a comprehensive approach that takes into account the severity of stenosis, patient symptoms, and individual risk factors, as well as the potential benefits and risks of surgical and medical therapies.

From the Research

Degree of Carotid Stenosis Indicated for Carotid Endarterectomy

• The degree of carotid stenosis is a critical factor in determining the benefit of carotid endarterectomy 2, 3, 4.
• Carotid endarterectomy is highly beneficial for patients with 70% to 99% symptomatic stenosis without near-occlusion, with an absolute risk reduction of 16.0% 4.
• For patients with 50% to 69% symptomatic stenosis, the benefit of surgery is marginal, with an absolute risk reduction of 4.6% 4.
• There is no evidence of benefit from surgery for patients with near-occlusions or those with less than 50% stenosis 4.
• The benefit of surgery also depends on other factors, including the delay to surgery after the presenting event, with the greatest benefit seen in patients operated on within two weeks of their last ischemic event 2, 4.

Clinical Characteristics and Benefit from Surgery

• Benefit from surgery is greatest in men, patients aged 75 years or older, and those with hemispheric rather than retinal antecedent events 2, 3, 4.
• The presence of other medical risk factors also increases the benefits from surgery 3.
• Careful preoperative risk assessment and maintenance of low rates of major perioperative complications are mandatory to maximize the benefits of surgery 3.

Comparison with Other Treatments

• Carotid endarterectomy is clearly superior to medical therapy for patients with symptomatic severe stenosis 5.
• The benefit from endarterectomy is muted in individuals with symptomatic moderate stenosis or asymptomatic stenosis, and decisions regarding surgical intervention must incorporate surgeon proficiency and patient comorbidity 5.
• There is currently a lack of evidence to support the use of carotid artery angioplasty and stenting in the routine management of carotid disease, except in selected patients with severe symptomatic stenosis for whom endarterectomy cannot be safely performed 5.