Carotid Revascularization: Threshold, Timing, and Best Technical Approach

Atherosclerotic internal carotid artery disease is a major contributor to ischemic stroke. Surgeons use a combination of carotid artery and brain imaging to determine if patients have symptomatic carotid stenosis. However, there remains widespread disagreement on the threshold, timing, and best technical approach to carotid revascularization in symptomatic patients.

Atherosclerotic internal carotid artery disease is a major contributor to ischemic stroke. Surgeons use a combination of carotid artery and brain imaging to determine if patients have symptomatic carotid stenosis. Carotid angiography was the gold standard for carotid stenosis diagnosis, but it has been replaced with noninvasive modalities—duplex ultrasonography, CT angiography (CTA) or MR angiography (MRA) of the neck—that can identify the degree of carotid stenosis.

In the early 1990s, two studies (the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial) provided new information about various treatment approaches. Additional studies have helped surgeons create treatment guidelines. Regardless, experts still cannot agree on the threshold, timing, and best technical approach to carotid revascularization in symptomatic patients.

In an article that appears electronically ahead of print in The Surgeon, two surgeons from the Northwestern University Feinberg School of Medicine, in Chicago, Illinois, compare and contrast carotid endarterectomy (CEA) or carotid stenting. They also discuss timing after symptom onset.

They report that all patients with symptomatic carotid stenosis need modification of cardiovascular risk factors plus antiplatelet and statin therapy.

Revascularization with carotid endarterectomy has a clear benefit in patients with stenosis >70%. Patients appear to show best outcomes when revascularization with CEA is performed within 2 days to 2 weeks of symptom onset. Some subgroups including women with moderate stenosis between 50% and 69% and patients with high surgical risk may benefit less from carotid endarterectomy.

No randomized prospective trials have compared CEA to best medical therapy, so the perceived benefit of CEA compared to best medical treatment alone may not be as significant.

Carotid stenting has been proposed as a less invasive alternative to CEA, but well designed trials have failed to demonstrate a clear, consistent benefit over CEA in symptomatic patients. Some trials have found stenting to be detrimental in symptomatic patients. Most guidelines recommend limiting carotid stenting to those patients at high risk for complications from CEA (eg, patients who have had prior neck surgery and patients at high risk for perioperative myocardial infarction).

The article also discusses available (and inconclusive) information about the transcervical approach, alteration in stent design, and embolic protection devices.