Most common peripheral vascular procedure performed in the U.S. today.
Nearly 100,000 procedures each year in the United States.
Carotid endarterectomy (CEA) is the surgical removal of atherosclerotic plaque from the carotid artery to prevent stroke in patients with significant carotid stenosis.
Symptomatic carotid stenosis represents the strongest indication for CEA.
For patients with 70-99% stenosis who have experienced recent TIA or non-disabling stroke, CEA reduces the 2-year risk of ipsilateral stroke from 26% to 9%.
The benefit is most pronounced when surgery is performed within 2 weeks of the index event.
For moderate stenosis (50-69%), CEA provides modest benefit, reducing 5-year stroke risk from 22.2% to 15.7%, requiring treatment of 22 patients to prevent one stroke.
Patients with less than 50% stenosis derive no benefit from surgery.
Asymptomatic carotid stenosis management is controversial.
While historical trials demonstrated benefit for 60-99% stenosis, contemporary medical therapy has substantially reduced stroke risk, challenging routine surgical intervention.
Current guidelines suggest CEA may be considered for asymptomatic stenosis ≥70% in carefully selected patients with low surgical risk, though the absolute benefit is modest (2-3% risk reduction over 5 years).
CEA is performed through a longitudinal neck incision exposing the carotid bifurcation. The procedure involves:
Arterial clamping with cerebral protection
Arteriotomy and plaque removal via endarterectomy plane
Closure with either primary suturing or patch angioplasty (bovine pericardium, Dacron, or vein)
Patch closure is generally preferred as it reduces perioperative stroke risk and restenosis compared to primary closure.
The procedure typically takes 1-2 hours under general or regional anesthesia.
Perioperative Outcomes
Contemporary CEA carries low perioperative risk.
The 30-day stroke or death rate ranges from 2.5-5.8% in symptomatic patients and 1.4-3% in asymptomatic patients.
In the large German registry in-hospital disabling stroke or death occurred in only 0.7% of asymptomatic patients.
Additional complications include:
Cranial nerve injury (5-10%, usually temporary)
Wound hematoma (5.5%)
Myocardial infarction (1-2%)
Hyperperfusion syndrome
MCEA vs. Carotid Artery Stenting
Multiple randomized trials have compared CEA with carotid artery stenting (CAS).
CEA demonstrates superior perioperative safety compared to transfemoral CAS, particularly for symptomatic stenosis.
In the Intracarotid Stenosis Study procedural stroke or death occurred in 7.4% with CAS versus 3.4% with CEA (risk ratio 2.16, p=0.0004).
The CREST trial showed similar findings (6.0% vs 3.2%).
CEA remains the gold standard for most patients, while CAS may be considered for high surgical risk patients (hostile neck anatomy, radiation-induced stenosis, restenosis after CEA).
Transcarotid artery revascularization (TCAR) represents a newer alternative showing outcomes comparable to CEA and superior to transfemoral CAS in select patients.
For symptomatic patients, the benefit of CEA is time-dependent.
Greatest benefit when performed within 2 weeks of the index event.
For crescendo TIAs (multiple TIAs in rapid succession), CEA can be safely performed within 24 hours with combined stroke/death rates of 4.1%, comparable to delayed intervention.
CEA provides durable stroke prevention in appropriately selected patients.
For severe symptomatic stenosis, the number needed to treat is 6 patients over 5 years to prevent one ipsilateral stroke.
However, contemporary medical therapy (intensive statin therapy, antiplatelet agents, blood pressure control) has substantially improved outcomes, particularly for asymptomatic disease.
The absolute benefit of CEA over medical therapy alone for asymptomatic stenosis is minimal (0.8% at 5 years), supporting medical therapy as an equally acceptable strategy in many patients.
Institutional and surgeon experience significantly impact outcomes.
Guidelines recommend surgeons maintain perioperative stroke/death rates below 3% for asymptomatic patients and below 6% for symptomatic patients.
Reduces stroke in patients with a 70% degree of stenosis or greater compared to medical management.
Surgery is of some benefit for patients with 50-69% symptomatic stenosis.
In asymptomatic stenosis endarterectomy of marginal benefit with 20 patients having to undergo surgery to prevent one stroke over 5 years.
Patients with a previous stroke or TIA and with severe (70-99%) carotid stenosis should undergo surgery.
Low complication rate with morbidity and mortality less than 6%.
Early postoperative mortality rate of only 1.6%.
Hospital stay averages 2 days in most centers.
Perioperative risk of stroke rates approximating 2% or less.
Restenosis occurs in roughly 5% of patients during the first year after endarterectomy and averages about 2% per year thereafter.
60% decrease in mortality when procedure performed by high-volume surgeons compared with low-volume surgeons, and a 30% decrease compared to medium-volume surgeons.
Decrease in postoperative stroke by 45% and 33% when treatment provided by a high-volume surgeon compared to a low-volume and medium-volume surgeons, respectively.
Cranial and cervical nerve injuries occur in 7.6-22% of patients.
Patients with contralateral carotid stenosis or advanced cardiac disease poor candidates for endarterectomy.
Patients with complete obstruction of the internal carotid artery have a minimal risk for emboli and are generally are not candidates for endarterectomy.
Among patients with high-grade stenosis without recent symptoms, stenting led to a lower risk of composite of perioperative stroke or death or ipsilateral stroke within four years than intensive medical management alone: Carotid endarterectomy did not lead to a significant benefit (CREST-2 investigators).