Carotid endarterectomy—An evidence-based review [RETIRED]

Abstract

Abstract-Objective:To assess the efficacy of carotid endarterectomy for stroke prevention in asymptomatic and symptomatic patients with internal carotid artery stenosis. Additional clinical scenarios, such as use of endarterectomy combined with cardiac surgery, are also reviewed. Methods: The authors selected nine important clinical questions. A systematic search was performed for articles from 1990 (the year of the last statement) until 2001. Additional articles from 2002 through 2004 were included using prespecified criteria. Two reviewers also screened for other relevant articles from 2002 to 2004. Case reports, review articles, technical studies, and single surgeon case series were excluded. Results: For several questions, high quality randomized clinical trials had been completed. Carotid endarterectomy reduces the stroke risk compared to medical therapy alone for patients with 70 to 99% symptomatic stenosis (16% absolute risk reduction at 5 years). There is a smaller benefit for patients with 50 to 69% symptomatic stenosis (absolute risk reduction 4.6% at 5 years). There is a small benefit for asymptomatic patients with 60 to 99% stenosis if the perioperative complication rate is low. Aspirin in a dose of 81 to 325 mg per day is preferred vs higher doses (650 to 1,300 mg per day) in patients undergoing endarterectomy. Conclusions: Evidence supports carotid endarterectomy for severe (70 to 99%) symptomatic stenosis (Level A). Endarterectomy is moderately useful for symptomatic patients with 50 to 69% stenosis (Level B) and not indicated for symptomatic patients with Ͻ50% stenosis (Level A). For asymptomatic patients with 60 to 99% stenosis, the benefit/risk ratio is smaller compared to symptomatic patients and individual decisions must be made. Endarterectomy can reduce the future stroke rate if the perioperative stroke/death rate is kept low (Ͻ3%) (Level A). Low dose aspirin (81 to 325 mg) is preferred for patients before and after carotid endarterectomy to reduce the rate of stroke, myocardial infarction, and death (Level A). NEUROLOGY 2005;65:794-801 Extracranial internal carotid artery stenosis accounts for 15 to 20% of ischemic strokes, depending on the population studied. Carotid endarterectomy (CE) is the most frequently performed operation to prevent stroke.The last statement from the American Academy of Neurology regarding CE was published in 1990. 1Since then, several multicenter trials have been completed and this statement reflects an update on major developments since 1990.Methods. Vascular neurologists were appointed by the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. A literature search was performed using Ovid Medline for relevant articles published from 1990 to 2001 using the following key words: carotid endarterectomy, carotid stenosis, carotid artery diseases, clinical trials. Further de-

Improvement and Impairment in Cognitive Function After Carotid Endarterectomy: Comparison of Objective and Subjective Assessments

“…5) In addition, neurosurgeons and/or patients' families often report postoperative subjective improvements or impairments in cognition for patients undergoing CEA. In fact, numerous studies have investigated objective changes in cognitive function following CEA using neuropsychological testing: just over half of these studies reported an improvement in cognition after CEA, but the remainder found no change.…”

Atherosclerotic Peripheral Vascular Disease Symposium II

“…13 It is estimated that carotid artery disease is responsible for 15% to 20% of all strokes. 14 The standard therapy for carotid artery revascularization is carotid endarterectomy (CEA), which is being compared with percutaneous carotid artery stent (CAS) placement in several patient subsets. Writing Group 5 focused on 3 current controversies:…”

Evaluating the Carotid Plaque: Going beyond Stenosis

“…Carotid stenosis accounts for 15–20% of all ischemic strokes [1]. Stroke recurrence in patients with symptomatic carotid stenosis can be prevented by carotid endarterectomy (CEA) with an absolute risk reduction of up to 17% [1].…”

“…Stroke recurrence in patients with symptomatic carotid stenosis can be prevented by carotid endarterectomy (CEA) with an absolute risk reduction of up to 17% [1]. Although there is irrefutable evidence that CEA is beneficial in patients with >70% symptomatic stenosis, identifying other patients who may benefit from CEA continues to be a significant challenge.…”