carotid endarterectomy in secondary prevention of stroke

Last edited 06/2019

Carotid endarterectomy is not without risks and these are operator dependent.

Surgery may be indicated if a patient has had a recent mild carotid-distribution ischaemia and has severe stenosis - between 70-99% luminal diameter - of the origin of the symptomatic internal carotid artery.

The risk of stroke is low in patients with stenosis less than 30% and does not justify surgery.

The European Carotid Surgery Trialists' Collaborative Group evaluated the value of endarterectomy in stenosis of 30-69%. This study revealed no benefit on patients who had recent cerebrovascular events and moderate-grade internal carotid artery stenosis at 4.5 years of follow-up.

The diagnosis of stenosis by angiography itself carries a risk of stroke - from 1-4%.

The National Clinical Guidelines for Stroke provide the following recommendations about carotid endarterectomy (1)

• any patient with a carotid area stroke and minor or absent disability should be considered for carotid endarterectomy
• carotid ultrasound should be undertaken on all patients who would be considered for carotid endarterectomy
• carotid endarterectomy should only be undertaken by a specialist surgeon with a proven low complication rate and only if the stenosis is measured at greater than 70% according to the ECST (European Carotid Surgery Trialists' Collaborative Group) criteria
• patients with a carotid stenosis of less than 70% or who have a totally occluded carotid artery do not benefit from carotid artery surgery and are best treated medically (3)

NICE have stated that (4):

Urgent carotid endarterectomy

• ensure that people with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of 50 to 99% according to the NASCET (North American Symptomatic Carotid Endarterectomy Trial) criteria:
  • are assessed and referred urgently for carotid endarterectomy to a service following current national standards
  • receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice)
• ensure that people with stable neurological symptoms from acute non-disabling stroke or TIA who have symptomatic carotid stenosis of less than 50% according to the NASCET criteria, or less than 70% according to the European Carotid Surgery Trial (ECST) criteria:
  • do not have surgery
  • receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice).

Reference:

• (1) The Royal College of Physicians. National Clinical Guidelines for Stroke. London, 2000.
• (2) European Carotid Surgery Trialists' Callobarotive Group (1996). Endarterectomy for moderate symptomatic carotid stenosis: interim results from the MRC European Carotid Surgery Trial. Lancet, 8 (347), 1591-3.
• (3) Prescriber (2001), 12 (19), 78-84.
• (4) NICE (May 2019). The diagnosis and acute management of stroke and transient ischaemic attacks