High-risk carotid endarterectomy

Area of Science:

• Vascular Surgery
• Cerebrovascular Disease Management

Background:

• Defining
• high-risk
• carotid endarterectomy (CEA) is crucial for patient selection and optimizing outcomes.
• Previous randomized controlled trials (RCTs) excluded many patients, leading to a potentially narrow definition of high-risk cases.

Purpose of the Study:

• To critically evaluate the concept of
• high-risk
• CEA by reviewing diverse evidence.
• To identify specific risk factors that genuinely increase perioperative morbidity and mortality during CEA.
• To inform appropriate patient selection for CEA and alternative interventions like carotid artery stenting (CAS).

Main Methods:

• Comprehensive literature review encompassing controlled randomized trials, retrospective population-based studies, large institution-based studies, and case series.
• Analysis of evidence regarding the impact of various patient characteristics and clinical scenarios on CEA outcomes.

Main Results:

• CEA can be safely performed in most patients previously considered
• high-risk
• , with low mortality and morbidity.
• Age (≥80 years) alone is not a significant high-risk criterion.
• Factors associated with slightly increased risk include contralateral carotid occlusion, carotid reoperation, and CEA after cervical radiation therapy.

Conclusions:

• The broad exclusion criteria from early CEA trials do not justify a restrictive approach to
• high-risk
• patients.
• Specific individual risk factors, such as prior radiation or reoperation, warrant careful consideration.
• Carotid artery stenting (CAS) should be reserved for well-defined high-risk patients due to limited evidence on its long-term efficacy compared to CEA.