CEA is recommended for 50–99% stenosis (NASCET) or 70–99% (ECST) in patients with TIA or non-disabling stroke. Ideally within 48 hrs, no later than 2 weeks.

🧠 Evidence & Indications

CEA developed in the 1950s; early use was without strong evidence.
Modern trials (NASCET, ECST) clearly defined its role in preventing recurrent stroke.
Timing matters: Greatest benefit if performed within 2 weeks of TIA/mild stroke.
Not useful if vessel is completely occluded – downstream damage has already occurred.
Benefit is strongest in symptomatic ≥70% stenosis; modest in 50–69%; no role <50%.
Operator experience matters → teams should perform a minimum annual number with low complication rates.
Formula for stenosis:
% stenosis = (1 - (minimal lumen ÷ post-stenotic diameter)) × 100

🔬 Investigations

First-line: Carotid Doppler USS.
Confirmatory: Contrast-enhanced MRA or CT angiography.
Consider dual-modality confirmation before intervention.

⚙️ The Procedure

Can be done under local or general anaesthesia.
Carotid artery exposed → clamped above/below lesion (shunt may be used to maintain flow).
Plaque removed → artery closed (primary or patch repair).
Duration: ~60–90 mins.
Most patients: overnight ICU/HDU stay for BP & neuro monitoring; home next day.

⚠️ Complications

Complication	Details
Ischaemic Stroke	Due to thrombus, dissection, or emboli. Requires urgent CT to exclude ICH and CTA for vessel status. Manage with antiplatelets/anticoagulation, sometimes re-exploration or stenting.
Restenosis	~5% at 2 yrs. Due to early neointimal hyperplasia or late atherosclerosis. Managed with medical therapy; some may need stenting or repeat surgery.
Hyperperfusion Syndrome	Loss of autoregulation → oedema, seizures, headache, ICH. Occurs Day 3–10. Manage with strict BP control and neuroimaging (CT/MRI).
Local Nerve Injury	Hypoglossal, vagus, glossopharyngeal nerves at risk (LMN palsy). Usually traction-related. Recovery over months; sometimes permanent.
Post-op ICH	Usually <72 hrs, worsened by anticoag/antiplatelets. Treat as acute ICH.
Wound issues	Dehiscence, infection – rare.

💊 Best Medical Therapy (alongside surgery)

Smoking cessation.
Antiplatelets: aspirin 75 mg od or clopidogrel 75 mg od.
High-dose statin therapy.
Strict BP management.
Lifestyle optimisation: exercise, diet, alcohol moderation.

📊 Secondary Stroke Prevention with CEA

Severity of stenosis	Relative Risk Reduction	Absolute Risk Reduction	NNT (2 yrs)
Occluded	Not for surgery	–	–
Symptomatic 70–99%	65%	13%	8
Symptomatic 50–69%	30%	7%	14
Symptomatic <50%	No benefit	–	–

💡 Surgery offers greatest benefit within days of the event. Benefit is limited in women, those with ocular events, lacunar strokes, contralateral occlusion, or distal vessel collapse. Minimal/no benefit after 3–6 months delay or in asymptomatic stenosis.

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Carotid Endarterectomy

🧠 Evidence & Indications

🔬 Investigations

⚠️ Complications

💊 Best Medical Therapy (alongside surgery)

📊 Secondary Stroke Prevention with CEA

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