Carotid endarterectomy (CEA) is a surgical procedure that involves removing atherosclerotic plaque causing internal carotid artery stenosis to prevent ischaemic stroke. It can be used in both the setting of symptomatic and asymptomatic carotid stenosis.

Percutaneous carotid arterial stenting (CAS) has been developed as an alternative to CEA, particularly in patients at high risk for post-surgical complications ¹.

Indications

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 patients 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.

Contraindications

Absolute contraindications include:

• significantly disabling stroke, precluding benefits of further surgical prophylaxis

• acute carotid occlusion

Relative contraindications:

• high risk of surgical complications with no benefit in overall risk when compared to medical therapy

Complications

• 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