Surgical therapy is indicated for asymptomatic carotid stenosis >60%; men in particular and those with a life expectancy >5 years have a proven benefit. The complication rate should be < 3%.
Furthermore, therapy is indicated in symptomatic carotid stenosis > 50 %.After a neurological event in carotid stenosis, carotid endarterectomy (CEA) should be performed as early as possible. In particular, CEA benefits:
- Men
- Patients
- > 70 years
- With insufficient stenoses
- Insufficiency collateral circulation (bypass circulation).
1st order
- Carotid thromboendarterectomy (carotid TEA; carotid endarterectomy, CEA) – in cases of high-grade carotid artery stenosis (narrowing), a thromboendarterectomy (TEA; surgical recanalization of the vessel) with dilatation plasty is performed [prerequisite is surgery at a center with a complication rate of < 3%].
Asymptomatic carotid stenosis: 5-year stroke risk is 5-6% for operated patients and 11% for non-operated patients.Symptomatic carotid stenosis: ECA results in an absolute stroke reduction of approximately 16%.
Notes on conservative adjunctive therapy in the setting of CEA:
- Acetylsalicylic acid (ASA).
- Drug and non-drug optimization of vascular risk factors.
2nd order
- Carotid artery stenting (CAS) – insertion of a self-expanding metal prosthesis that holds the narrowed artery open [requires surgery at a center with a complication rate of <6%]; indicated for:
- Increased surgical risk
- Contralateral paresis of the recurrent laryngeal nerve (paralysis of the laryngeal nerve)
- Radiogenic stenosis – narrowing of the artery caused by ionizing radiation.
- Difficult anatomical conditions such as surgically inaccessible sites.
- Higher grade intracranial or intrathoracic stenosis.
- Tandem stenosis – two stenoses in succession in one artery.
- Condition after CEA
Further notes
- A long-term study (10 years) showed that carotid stenting (implantation of a stent in the carotid artery) in patients with symptomatic carotid stenosis protected them as well from subsequent apoplexy (stroke) as classic carotid thromboendarterectomy (CEA), in which the narrowed artery is peeled out, ie. That is, the calcium deposits are surgically removed.However, the stent group showed a 71% increase in risk after five years (cumulative risk for endarterectomy: 9.4% versus 15.2% for carotid stenting).
- Another study based on a U.S. government insurer Medicare database questions the benefit of carotid stenting:
- 1.7% of patients died while still in the hospital or in the first 30 days postoperatively (after surgery)
- 3.3% suffered a TIA (transient ischemic attack; temporary circulatory disturbance of the brain) or an apoplexy (stroke) during the above-mentioned period, 2.5% a myocardial infarction (heart attack)
- At 2 years after stent implantation, 37% of symptomatic and 28% of asymptomatic stenosis patients were dead.
It is possible that the poor prognosis may explain the high mean age of 76 years and associated comorbidities (concomitant diseases). The two-year mortality rate (death rate) of those over 80 years of age was nearly 42%.
