carotid endarterectomy (CEA)
Jump to navigation
Jump to search
Introduction
Surgical removal of deposits in the walls of the carotid artery that, when present, have the effect of narrowing its lumen.
Indications
- patients with carotid stenosis of 70-99% (> 80%[2]) probably benefit from carotid endarterectomy
- symptomatic patients over 75 years of age with > 50% stenosis[3][17], in otherwise good health
- asymptomatic internal carotid stenosis of 70-99% in patients < 75 years of age[18]
- benefit greatest when carotid endarterectomy is performed < 2 weeks after last symptomatic event[17][18]
* NO indication for carotid endarterectomy for asymptomatic patients prior to coronary artery bypass grafting (CABG); endarterectomy can be safely postponed until after CABG.
Complications
- perioperative stroke risk is 2.3-4.5% versus 9.8% annually (80-90% stenosis) or 14.4% (90-99%) stenosis for aspirin therapy alone[2]
- perioperative subclinical cerebral ischemia occurs commonly
- cognitive deficits can result[22]
- annual risk of stroke after carotid endarterectomy may be as high as 5%
- diminished risk of stroke after carotid endarterectomy (CEA) relative to carotid artery stenting (CAS) in the elderly[23]
- risk factors* for perioperative complications
- occlusion of the contralateral internal carotid artery of 80-99%[25]
- thrombus* visible of angiography of lesion in symptomatic patient
- lesion compatible with ischemic lesion on CT in territory of affected internal carotid artery
- history of diabetes mellitus
- diastolic blood pressure > 90 mm Hg
- irregular or ulcerated plaque on angiography
- symptomatic left internal carotid artery for right-handed surgeons
- emergency surgery[25]
- previous stroke (as opposed to TIA)[25]
- comorbidities: cardiopulmonary disease, renal faulure[25]
- left carotid endarterectomy more difficult for right-handed surgeon
- mortality risk (0.4-0.5%)[23]
- 30-day rate of stroke or death is 3%[25]
- 30-day incidence of nonstroke major complications is 5.3%[25]
* 5 year stroke-free survival for lesions with > 70% stenosis is still improved with endarterectomy, despite risk factors EXCEPT for visible intraluminal thrombus
Management
- aspirin 81 or 325 mg QD before carotid endarterectomy & at least 3 months afterwards[18]
Notes
- overall benefits are small (5% risk reduction over 5 years)[18]
- aggressive risk factor modification may further reduce benefit of carotid endarterectomy over medical management[18]
- 10 year reduction in risk of stroke after successful CEA in asymptomatic patients (11% vs 17%); perioperative risk of 3%[21]
More general terms
Additional terms
- carotid artery disease
- carotid artery stenting (CAS)
- internal carotid artery (ICA)
- ischemic stroke
- transient ischemic attack (TIA)
References
- ↑ nlmpubs.nlm.nih.gov/hstat/ahcpr/
- ↑ 2.0 2.1 2.2 Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
- ↑ 3.0 3.1 Journal Watch 21(11):87, 2001
- ↑ Rick Smith, MD, Jewish Home for the Aging, UCLA affliate
- ↑ Bogousslavsky et al, North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group, Stroke 30:282, 1999
- ↑ Barnett et al, North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group, JAMA 283:1429, 2000
- ↑ Izitari et al, North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group, N Engl J Med 342:1693, 2000
- ↑ Kristler & Furie N Engl J Med 342:1743, 2000
- ↑ Barnett & Meldrum, Arch Neurol 57:40, 2000
- ↑ Branett & Broderick, Neurology 55:746, 2000
- ↑ Chaturvedi & Femino Neurology 50:1927, 1998
- ↑ Rothwell Lancet 357:1142, 2001
- ↑ Alamowitch et al, North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group, Lancet 357:1154, 2001
- ↑ Chaturvedi, Arch Neurol 56:879, 1999
- ↑ Wennberg et al, JAMA 279:1278, 1998
- ↑ Castaldo, Arch Neurol 56:877, 1999 (asymptomatic stenosis)
- ↑ 17.0 17.1 17.2 Journal Watch 24(9):76, 2004
Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ; Carotid Endarterectomy Trialists Collaboration. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet. 2004 Mar 20;363(9413):915-24. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15043958 - ↑ 18.0 18.1 18.2 18.3 18.4 18.5 Journal Watch 24(12):93, 2004 Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, Thomas D; MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004 May 8;363(9420):1491-502. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15135594
- ↑ Chaturvedi S et al Carotid endarterectomy - An evidence-based review: Reports of the Therapeutics and Technnology Assessment Subcommittee of the American Academy of Neurology Neurology 2005; 65:794 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16186516
- ↑ Press MJ et al, Predicting medical and surgical complications of carotid endarterectomy: Comparing the risk indexes. Arch Intern Med 2006, 166:914 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16636219
- ↑ 21.0 21.1 Halliday A et al, 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. The Lancet 2010, 376:1074-1084 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20870099
- ↑ 22.0 22.1 Zhou W et al. Prospective neurocognitive evaluation of patients undergoing carotid interventions. J Vasc Surg 2012 Dec; 56:1571. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22889720
- ↑ 23.0 23.1 23.2 Antoniou GA et al Meta-analysis and Meta-Regression Analysis of Outcomes of Carotid Endarterectomy and Stenting in the Elderly. JAMA Surg. Published online October 23, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24154858 <Internet> http://archsurg.jamanetwork.com/article.aspx?articleid=1757343
Darling RC Carotid Intervention in the Elderly. Who Is Old and Who Benefits? JAMA Surg. Published online October 23, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24154829 <Internet> http://archsurg.jamanetwork.com/article.aspx?articleid=1757342 - ↑ Paraskevas KI, Veith FJ. The Indications of Carotid Artery Stenting in Symptomatic Patients May Need To Be Reconsidered. Ann Vasc Surg. 2014 Oct 8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25305422
- ↑ 25.0 25.1 25.2 25.3 25.4 25.5 25.6 Bennett KM et al. Predictors of 30-day postoperative stroke or death after carotid endarterectomy using the 2012 carotid endarterectomy- targeted American College of Surgeons National Surgical Quality Improvement Program database. J Vasc Surg 2015 Jan; 61:103 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25065581 <Internet> http://www.jvascsurg.org/article/S0741-5214%2814%2901126-4/abstract
- ↑ 26.0 26.1 Liang P, Solomon Y, Swerdlow NJ et al. In-hospital outcomes alone underestimate rates of 30-day major adverse events after carotid artery stenting. J Vasc Surg 2020 Apr; 71:1233. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32063441
Boitano LT, DeCarlo C, Schwartz MR et al. Surgeon specialty significantly affects outcome of asymptomatic patients after carotid endarterectomy. J Vasc Surg 2020 Apr; 71:1242. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31831310
Edla S, Atti V, Kumar V et al. Comparison of nationwide trends in 30-day readmission rates after carotid artery stenting and carotid endarterectomy. J Vasc Surg 2020 Apr; 71:1222 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31564583