Surgery Insight: Carotid Endarterectomy -- Which Patients to Treat and When?

Summary and Introduction

Summary

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.

Introduction

Over the past 15 years evidence has accumulated to supports the use of interventions that ensure stroke-free survival in patients with internal carotid artery (ICA) stenosis. Investigations have shown that most patients with symptomatic high-grade stenosis and many with moderate-grade stenosis benefit from carotid endarterectomy (CEA). Despite the introduction of carotid stenting and improvements in medical therapy for patients with atherosclerotic disease, CEA is still performed frequently in patients with symptomatic and asymptomatic stenosis. The completion of several studies in patients considered 'high-risk' CEA candidates and a few comparative studies of CEA and carotid stenting have provided new information, but the results are widely perceived as disappointing. Here, we shall review the role of CEA in stroke prevention.