carotid endarterectomy in secondary prevention of stroke

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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).

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Last edited 06/2019

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