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carotid endarterectomy (CEA)

Surgical removal of deposits in the walls of the carotid artery that, when present, have the effect of narrowing its lumen. Indications: 1) patients with carotid stenosis of 70-99% (> 80% [2]) probably benefit from carotid endarterectomy 2) symptomatic patients over 75 years of age with > 50% stenosis [3,17], in otherwise good health 3) asymptomatic internal carotid stenosis of 70-99% in patients < 75 years of age [18] 4) benefit greatest when carotid endarterectomy is performed < 2 weeks after last symptomatic event [17,18] * NO indication for carotid endarterectomy for asymptomatic patients prior to coronary artery bypass grafting (CABG); endarterectomy can be safely postponed until after CABG. Complications: 1) perioperative stroke risk is 2.3-4.5% versus 9.8% annually (80-90% stenosis) or 14.4% (90-99%) stenosis for aspirin therapy alone [2] 2) perioperative subclinical cerebral ischemia occurs commonly - cognitive deficits can result [22] 3) annual risk of stroke after carotid endarterectomy may be as high as 5% 4) diminished risk of stroke after carotid endarterectomy (CEA) relative to carotid artery stenting (CAS) in the elderly [23] - 30 day risk for stroke, cardiac event or death 3.2-4.9% for CEA lower than that for CAS 5.6-6.3% [26] 5) risk factors* for perioperative complications a) occlusion of the contralateral internal carotid artery of 80-99% [25] b) thrombus* visible of angiography of lesion in symptomatic patient c) lesion compatible with ischemic lesion on CT in territory of affected internal carotid artery d) history of diabetes mellitus e) diastolic blood pressure > 90 mm Hg f) irregular or ulcerated plaque on angiography g) symptomatic left internal carotid artery for right-handed surgeons h) emergency surgery [25] i) previous stroke (as opposed to TIA) [25] j) comorbidities: cardiopulmonary disease, renal faulure [25] 6) left carotid endarterectomy more difficult for right-handed surgeon 7) mortality risk (0.4-0.5%) [23] 8) 30-day rate of stroke or death is 3% [25] 9) 30-day incidence of nonstroke major complications is 5.3% [25] * 5 year stroke-free survival for lesions with > 70% stenosis is still improved with endarterectomy, despite risk factors EXCEPT for visible intraluminal thrombus Management: - aspirin 81 or 325 mg QD before carotid endarterectomy & at least 3 months afterwards [18] Notes: 1) overall benefits are small (5% risk reduction over 5 years) [18] 2) aggressive risk factor modification may further reduce benefit of carotid endarterectomy over medical management [18] 3) 10 year reduction in risk of stroke after successful CEA in asymptomatic patients (11% vs 17%); perioperative risk of 3% [21]

Related

carotid artery disease carotid artery stenting (CAS) internal carotid artery (ICA) ischemic stroke transient ischemic attack (TIA)

General

carotid artery revascularization carotid/vertebral/subclavian endarterectomy

References

  1. nlmpubs.nlm.nih.gov/hstat/ahcpr/
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
  3. Journal Watch 21(11):87, 2001
  4. Rick Smith, MD, Jewish Home for the Aging, UCLA affliate
  5. Bogousslavsky et al, North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group, Stroke 30:282, 1999
  6. Barnett et al, North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group, JAMA 283:1429, 2000
  7. Izitari et al, North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group, N Engl J Med 342:1693, 2000
  8. Kristler & Furie N Engl J Med 342:1743, 2000
  9. Barnett & Meldrum, Arch Neurol 57:40, 2000
  10. Branett & Broderick, Neurology 55:746, 2000
  11. Chaturvedi & Femino Neurology 50:1927, 1998
  12. Rothwell Lancet 357:1142, 2001
  13. Alamowitch et al, North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group, Lancet 357:1154, 2001
  14. Chaturvedi, Arch Neurol 56:879, 1999
  15. Wennberg et al, JAMA 279:1278, 1998
  16. Castaldo, Arch Neurol 56:877, 1999 (asymptomatic stenosis)
  17. Journal Watch 24(9):76, 2004 - Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ; Carotid Endarterectomy Trialists Collaboration. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet. 2004 Mar 20;363(9413):915-24. PMID: 15043958
  18. Journal Watch 24(12):93, 2004 Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, Thomas D; MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004 May 8;363(9420):1491-502. PMID: 15135594
  19. Chaturvedi S et al Carotid endarterectomy - An evidence-based review: Reports of the Therapeutics and Technnology Assessment Subcommittee of the American Academy of Neurology Neurology 2005; 65:794 PMID: 16186516
  20. Press MJ et al, Predicting medical and surgical complications of carotid endarterectomy: Comparing the risk indexes. Arch Intern Med 2006, 166:914 PMID: 16636219
  21. Halliday A et al, 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. The Lancet 2010, 376:1074-1084 PMID: 20870099
  22. Zhou W et al. Prospective neurocognitive evaluation of patients undergoing carotid interventions. J Vasc Surg 2012 Dec; 56:1571. PMID: 22889720
  23. Antoniou GA et al Meta-analysis and Meta-Regression Analysis of Outcomes of Carotid Endarterectomy and Stenting in the Elderly. JAMA Surg. Published online October 23, 2013 PMID: 24154858 http://archsurg.jamanetwork.com/article.aspx?articleid=1757343 - Darling RC Carotid Intervention in the Elderly. Who Is Old and Who Benefits? JAMA Surg. Published online October 23, 2013 PMID: 24154829 http://archsurg.jamanetwork.com/article.aspx?articleid=1757342
  24. Paraskevas KI, Veith FJ. The Indications of Carotid Artery Stenting in Symptomatic Patients May Need To Be Reconsidered. Ann Vasc Surg. 2014 Oct 8. PMID: 25305422
  25. Bennett KM et al. 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 Jan; 61:103 PMID: 25065581 http://www.jvascsurg.org/article/S0741-5214%2814%2901126-4/abstract
  26. Liang P, Solomon Y, Swerdlow NJ et al. In-hospital outcomes alone underestimate rates of 30-day major adverse events after carotid artery stenting. J Vasc Surg 2020 Apr; 71:1233. PMID: 32063441 - Boitano LT, DeCarlo C, Schwartz MR et al. Surgeon specialty significantly affects outcome of asymptomatic patients after carotid endarterectomy. J Vasc Surg 2020 Apr; 71:1242. PMID: 31831310 - Edla S, Atti V, Kumar V et al. Comparison of nationwide trends in 30-day readmission rates after carotid artery stenting and carotid endarterectomy. J Vasc Surg 2020 Apr; 71:1222 PMID: 31564583