Carotid Endarterectomy: When and in Whom?

Carotid endarterectomy has been a widely used method of preventing primary or secondary cerebrovascular ischemic events since the 1950s. Over the past several years, the interest in this surgical procedure has increased due to the publication of several large randomized trials comparing best medical therapy (antithrombotic) with carotid endarterectomy. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) has demonstrated a risk reduction of 65% in patients who underwent carotid endarterectomy for symptomatic carotid stenosis. The Asymptomatic Carotid Atherosclerosis Study (ACAS) also demonstrated a benefit of carotid endarterectomy, however, in a group of asymptomatic patients. There was an approximate reduction of 6% in stroke in patients undergoing carotid endarterectomy in this series. Carotid endarterectomy is the treatment of choice in patients with symptomatic extracranial carotid atherosclerosis. Data is now emerging that this is also an effective therapy in patients with asymptomatic carotid stenosis. The perioperative stroke risk by the surgeon performing the procedure and the patient's co‐morbid medical conditions are important factors to consider before proceeding with surgical treatment of this disorder.