Carotid endarterectomy (CEA) is a surgical procedure that involves removing athersclerotic plaque causing internal carotid artery stenosis in order to to prevent ischaemic stroke. It can be used in both in the setting of symptomatic and asymptomatic carotid stenosis.
More recently, percutaneous carotid arterial stenting (CAS) has been developed as an alternative to CEA, particularly in patients at high risk for post-surgical complications 1.
According to NICE (UK) guidelines patients with suspected TIA or non-disabling stroke should be considered for endarterectomy if:
- symptomatic carotid stenosis of 50-99% according to NASCET criteria
- symptomatic stenosis of 70-99% according to ECST criteria
The European Society for Vascular Surgery guidelines advise CEA if:
- >50% carotid stenosis in patient with one or more TIA in the last six months 2
There is less consensus on prophylactic CEA in patients who are found to have significant carotid artery stenosis without neurological symptoms. However, the ASCT-1 trial evaluated the prophylactic endarterectomy for asymptomatic stenosis and found a significant reduction in 10 year mortality 3. Unfortunately, they did not use a uniform minimum value for luminal stenosis and this is being further evaluated by ASCT-2.
Absolute contraindications include:
- significantly disabling stroke, precluding benefits of further surgical prophylaxis
- acute carotid occlusion
- high risk of surgical complications with no benefit in overall risk when compared to medical therapy
- stroke (3% incidence at 30 days) 4
- myocardial infarction
- nerve injury (commonly hypoglossal, accessory, laryngeal or mandibular nerves) 5
- hyperperfusion syndrome after carotid endarterectomy (1-2%): headache, seizures and intracranial haemorrhage 6
- 1. Gahremanpour A, Perin EC, Silva G. Carotid artery stenting versus endarterectomy: a systematic review. Tex Heart Inst J. 2013;39 (4): 474-87. Free text at pubmed - Pubmed citation
- 2. Ricotta JJ, Aburahma A, Ascher E et-al. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J. Vasc. Surg. 2011;54 (3): e1-31. doi:10.1016/j.jvs.2011.07.031 - Pubmed citation
- 3. Halliday A, Harrison M, Hayter E et-al. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet. 2010;376 (9746): 1074-84. doi:10.1016/S0140-6736(10)61197-X - Free text at pubmed - Pubmed citation
- 4. Bennett KM, Scarborough JE, Shortell CK. Predictors of 30-day postoperative stroke or death after carotid endarterectomy using the 2012 carotid endarterectomy-targeted American College of Surgeons National Surgical Quality Improvement Program database. J. Vasc. Surg. 2015;61 (1): 103-11. doi:10.1016/j.jvs.2014.05.100 - Pubmed citation
- 5. Beasley WD, Gibbons CP. Cranial nerve injuries and the retrojugular approach in carotid endarterectomy. Ann R Coll Surg Engl. 2008;90 (8): 685-8. doi:10.1308/003588408X318138 - Free text at pubmed - Pubmed citation
- 6. Karapanayiotides T, Meuli R, Devuyst G et-al. Postcarotid endarterectomy hyperperfusion or reperfusion syndrome. Stroke. 2004;36 (1): 21-6. doi:10.1161/01.STR.0000149946.86087.e5 - Pubmed citation