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Surgery Insight: carotid endarterectomy—which patients to treat and when?

Nature Clinical Practice Cardiovascular Medicine volume 4, pages 621–629 (2007)Cite this article

Abstract

Over the past 15 years, we have witnessed a resurgence of surgery for prevention of ischemic stroke. Landmark trials including the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial have explored the role of carotid endarterectomy in this context, comparing the procedure with best medical treatment in patients with high-grade stenosis of the internal carotid artery and transient ischemic attack or minor nondisabling stroke in the same territory. Here, we discuss the lessons learnt from these trials, and review the Asymptomatic Carotid Atherosclerosis Study and the Asymptomatic Carotid Surgery Trial, which attempted to resolve the rather vexing issue of surgical treatment for patients with asymptomatic internal carotid artery stenosis. We also review the best medical treatment for patients undergoing carotid endarterectomy in the perioperative period, and examine the risk of ischemic stroke after CABG surgery, both when this procedure is performed alongside endarterectomy and when CABG surgery and endarterectomy are performed as a two-staged procedure.

Key Points

  • The role of carotid endarterectomy (CEA) in stroke prevention has been greatly clarified in the last 15 years

  • Early CEA is beneficial in patients with symptomatic carotid stenosis greater than 50%, provided the institutional perioperative complication rate is less than 6%

  • CEA is beneficial in patients with symptomatic carotid stenosis even in presence of carotid ulceration, contralateral carotid occlusion and to a lesser extent carotid near occlusion

  • Benefit gained from CEA in asymptomatic carotid stenosis is reduced and should probably be restricted to certain patient subgroups, provided the institutional perioperative complication rate is less than 3%

  • CEA is performed to prevent stroke during CABG surgery, but despite theoretical promise, the combined procedure has not yet been conclusively shown to be safer than the staged approach

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Acknowledgements

Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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Authors and Affiliations

  1. at the Department of Neurology, K Rajamani is Assistant Professor, and S Chaturvedi is Professor of Neurology and Director of the Comprehensive Stroke Program, Wayne State University, Detroit, MI, USA.,

    Kumar Rajamani & Seemant Chaturvedi

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Correspondence to Seemant Chaturvedi.

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Rajamani, K., Chaturvedi, S. Surgery Insight: carotid endarterectomy—which patients to treat and when?. Nat Rev Cardiol 4, 621–629 (2007). https://doi.org/10.1038/ncpcardio1008

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