Carotid Endarterectomy in the Era of Stenting and Optimal Medical Therapy

Cardiovascular events, including stroke and acute myocardial infarction (AMI), remain the leading causes of death worldwide. This study aimed to review the scientific literature evaluating carotid endarterectomy as a first-line intervention for carotid artery disease. A literature review was conducted, including 40 articles published between 1977 and 2025, retrieved from Scientific Electronic Library Online (SciELO), Google Scholar, and MEDLINE (PubMed). Patients with carotid atherosclerotic disease should undergo individualized stroke risk assessment using validated imaging modalities to guide treatment selection. This review aimed to evaluate the current evidence regarding carotid endarterectomy (CEA) within the contemporary management of carotid artery stenosis. A structured review of 40 studies published between 1977 and 2025 was conducted.. The analyzed literature demonstrates that CEA provides a clear benefit in patients with symptomatic carotid stenosis ≥70%, and selected patients with 50-69% stenosis, when performed in experienced centers with low perioperative risk, in accordance with current European Society for Vascular Surgery (ESVS) guidelines. In contrast, for asymptomatic carotid stenosis, recent evidence from the Carotid Revascularization Endarterectomy versus Stenting Trial-2 (CREST-2) era highlights the critical role of optimized medical therapy, with revascularization reserved for carefully selected high-risk patients. In this population, CEA should be considered only when the procedural risk is low and the life expectancy is sufficient to derive long-term benefit. In conclusion, CEA remains an effective intervention for stroke prevention in appropriately selected patients, particularly those with symptomatic disease, while contemporary management increasingly emphasizes individualized decision-making and aggressive medical therapy, especially in asymptomatic patients.