Carotid Endarterectomy: Is It Still a Gold Standard?

Abstract

Extracranial internal carotid artery stenosis accounts for 15–20% of ischemic strokes. Carotid endarterectomy has high efficacy in stroke prevention in selected patients with symptomatic (age <80 years) and asymptomatic carotid stenosis (age <75 years). Randomized clinical trials demonstrated that carotid endarterectomy reduces the stroke risk, compared to medical therapy alone, for patients with 70–99% symptomatic stenosis with 16% absolute risk reduction at 5 years. The benefit for patients with 50–69% symptomatic stenosis is lower i.e. absolute risk reduction 4.6% at 5 years. Endarterectomy is not indicated for symptomatic patients with <50% stenosis. There is no need for time-delay for surgery in patients after transient ischemic attack or minor stroke. Patients with more extensive strokes or hemorrhage should undergo surgery after 4–6 weeks following initial symptoms. Carotid endarterectomy for asymptomatic stenosis reduces the risk of ipsilateral stroke, and any stroke, by approximately 30% over 3 years. However, the absolute risk reduction is small over the first few years and decision should be based on individual institutional experience. In all situations, the best medical therapy should accompany surgery. In the recent years, appearance of angioplasty, stenting, and distal protection procedures provides competitive alternatives to classical endarterectomy. However, long-term benefits of carotid angioplasty should be confirmed by bigger, randomized, comparative clinical trials.

Transient Hyperperfusion after Superficial Temporal Artery/Middle Cerebral Artery Bypass Surgery as a Possible Cause of Postoperative Transient Neurological Deterioration

“…The reported incidence of cerebral hyperperfusion syndrome following CEA and stenting (1.1–2%) is much lower than the reported incidence of postbypass TND following STA-MCA anastomosis (4–20%), although cerebral hyperperfusion syndrome following CEA or stenting includes some fatal hemorrhages (0.6–0.67%) [9,10,11,12,13]. These procedures are quite different from each other, in that CEA and stenting restore high-flow perfusion to one hemisphere whereas STA-MCA bypass restores low-flow focal perfusion.…”

Endogenous Expression of C-Reactive Protein Is Increased in Active (Ulcerated Noncomplicated) Human Carotid Artery Plaques

“…These findings seem to be important as so far all advanced carotid plaques in patients scheduled for endarterectomy have been considered as end-stage, and plaque progression measured by ultrasound usually estimates the grade of carotid stenosis rather than the exact stage of plaque activity. 20 CRP is frequently deposited in atherosclerotic lesions from human and animal models; however, its origin and the pathological significance of CRP in these lesions are not completely understood. In humans, there is little information on CRP expression in vascular tissues.…”

Endarterectomy, Best Medical Treatment or Both for Stroke Prevention in Patients with Asymptomatic Carotid Artery Stenosis

“…– A large amount of evidence must guide the selection of appropriate patients for symptomatic CEA based on large multicentre randomized clinical trials (NASCET, ECST) and meta-analysis [42]. …”