and the pharyngeal branch of the vagus nerve separate the internal from the external carotid artery. Location and influence of the carotid baroreceptor Baroreceptors are stretch-sensitive mechanoreceptors that respond to alterations in blood pressure. The carotid sinus baroreceptors are located within the adventitia of the origin of the internal carotid artery and are innervated by the sinus nerve of Hering, which is a branch of glossopharyngeal nerve. In response to low blood pressure, the nerve fibers decrease their firing rates, stimulating the sympathetic nervous system and inhibiting the parasympathetic nervous system via a centrally acting mechanism. Carotid sinus reactivity may be altered in patients with carotid atherosclerosis. Patients display varying degrees of heart rate or blood pressure alterations during manipulation of the carotid bifurcation, carotid clamping, or postoperatively following CEA [76]. Endarterectomy, removal of atheromatous debris, and reconstruction of the carotid artery may increase tension on the carotid sinus baroreceptor, increasing its activity [77]. The opposite is also possible if damage to the carotid sinus or sinus nerve occurs. As an example, eversion endarterectomy requires division of the carotid artery, and as a result, the longitudinal fibers of https://www.uptodate.com/contents/carotid-endarterectomy/print 12/45 7/5/23, 11:36 AM Carotid endarterectomy - UpToDate the carotid sinus nerve are transected. A study that measured baroreceptor sensitivity following CEA found increased sensitivity with conventional CEA and decreased sensitivity with an eversion technique [78]. Correspondingly, postoperative blood pressures were significantly increased for eversion compared with conventional CEA (systolic: 127, diastolic: 64, mean: 86; versus systolic: 111, diastolic: 55, mean: 75). Compensation over time occurs due to intact baroreceptor mechanisms from the contralateral side and aortic arch. (See 'Conventional versus eversion endarterectomy' below.) ANESTHESIA Carotid endarterectomy can be performed using local/regional anesthesia or general anesthesia. Ideally, surgical and anesthetic teams should be competent in both techniques because a patient might prefer, or there might be a medical reason to choose, one anesthetic technique rather than another [79]. In an analysis of 26,070 cases in the American College of Surgeons National Surgical Quality Improvement Program database, general anesthesia was used in 84.6 percent and regional anesthesia was used in 15.4 percent of cases [80]. In another study looking at over 75,000 cases, 8.9 percent were performed under local/regional anesthesia. CEA performed under general anesthesia was associated with twice the odds of in-hospital myocardial infarctions, four times the odds of acute congestive heart failure, 1.5 times the odds of hemodynamic instability, and 1.8 times the odds of staying in the hospital for >1 day. However, the authors noted that the overall risk of adverse cardiac events after CEA was overall low, which made the differences clinically irrelevant [81]. Local/regional anesthesia may be more beneficial for some patients but can be uncomfortable for the patient and may necessitate urgent conversion to general anesthesia or urgent shunt placement. (See "Anesthesia for carotid endarterectomy and carotid stenting", section on 'Selection of the anesthetic technique'.) Anesthetic choice The use of general anesthesia for CEA or performing awake carotid surgery with local anesthesia (with or without cervical block) is generally determined by surgeon preference and patient characteristics and preference. The available evidence suggests that the choice of anesthetic technique has no significant impact on clinically important outcomes after CEA. (See "Anesthesia for carotid endarterectomy and carotid stenting", section on 'Selection of the anesthetic technique'.) Assessing brain perfusion Although 80 to 85 percent of patients tolerate clamping of the carotid artery without consequence, the collateral circulation via the circle of Willis should be https://www.uptodate.com/contents/carotid-endarterectomy/print 13/45 7/5/23, 11:36 AM Carotid endarterectomy - UpToDate assessed in all patients who do not undergo mandatory shunting. (See 'Preoperative imaging' above and 'Carotid shunting' below.) During local/regional anesthesia in cooperative patients, clinical assessments are made during the procedure by monitoring mental status, speech, and extremity function. Agitation, slurred speech, disorientation, and extremity weakness are indications for shunt placement. During general anesthesia, assessment of cerebral perfusion to determine which patients should receive a shunt can be accomplished with a variety of methods (eg, measurement of carotid stump pressure, transcranial Doppler, somatosensory evoked potentials, jugular venous oxygen saturation). The most commonly used methods are discussed in detail elsewhere. (See 'Carotid shunting' below and "Anesthesia for carotid endarterectomy and carotid stenting", section on 'Neuromonitoring modalities'.) SURGICAL TECHNIQUE Endarterectomy procedure General conduct of operation CEA is performed through a neck incision, either a longitudinal one along the anterior border of the sternocleidomastoid muscle or with a transverse incision in a skin crease at the level of carotid bulb. For the latter incision, preoperative imaging with ultrasound will guide the surgeon to the optimal placement of the incision. No significant differences between these approaches have been identified in terms of stroke, wound complications, or nerve complications [82]. The underlying platysma muscle and subcutaneous tissues are divided, the carotid sheath exposed, and the internal carotid artery is carefully identified and dissected. The extent of exposure of the artery is dependent upon the distribution of disease determined by intraoperative findings. Typically, dissection is needed from the common carotid artery to a point distal to the bifurcation of the internal carotid artery and external carotid artery that is beyond palpable internal carotid artery plaque to allow for clamping of normal soft artery. Following carotid dissection, the patient is systemically anticoagulated (heparin given as bolus, or using an alternative agent, as indicated). Monitoring the activated clotting time is not usually needed, owing to the short duration of carotid clamping, which is typically less than an hour. Carotid stump pressures can be obtained to help guide the need for shunt placement. The internal, common, and external arteries are clamped sequentially; the internal carotid artery is always clamped first to prevent embolization. A needle attached to a transducer is introduced into the common carotid artery. The clamp on the internal carotid artery is released and a https://www.uptodate.com/contents/carotid-endarterectomy/print 14/45 7/5/23, 11:36 AM Carotid endarterectomy - UpToDate waveform is obtained. Mean pressures greater than 30 to 50 mmHg imply adequate collateralization via the circle of Willis down the ipsilateral carotid artery. Lower stump pressures are an indication for shunt placement, and higher pressures are associated with stroke rates <0.5 percent [83]. Critics of this technique caution that pressures are only obtained after initial clamping and, therefore, represent a "snapshot" in time. In addition, the criteria above should be used with caution in patients who have suffered prior ipsilateral strokes (potential vulnerable penumbra surrounding the prior infarct) since there is a poor correlation between adequate perfusion pressures and outcomes in this setting. The accuracy of the pressure in the face of a preocclusive (string) lesion may also be questionable. (See 'Assessing brain perfusion' above.) After measurement of the stump pressure, the clamp is placed back on the distal internal carotid artery, and the transducer needle is removed. Manipulation of the carotid bulb during CEA not infrequently results in hemodynamic instability intraoperatively and in the early postoperative period [84]. Adequate cerebral perfusion pressure (ie, systolic blood pressure) should be maintained during periods of hemodynamic instability to avoid low cerebral blood flow and cerebral ischemia. A longitudinal arteriotomy is performed below the level of the bifurcation and extended proximally and distally. If shunting is required, the shunt is placed after the vessel is opened and prior to the endarterectomy. For patients who are undergoing general anesthesia, some surgeons routinely place a carotid shunt while others use cerebral perfusion monitoring to guide the need for selective shunt placement. For these patients and those undergoing awake CEA using local anesthesia (with or without cervical block), the endarterectomy is often completed prior to the need to place a shunt, as indicated by brain monitoring. (See 'Carotid shunting' below and 'Assessing brain perfusion' above.) The carotid plaque, which is consistently found at the carotid bifurcation and the origin of the internal carotid artery, is then freed and removed through a dissection plane developed in the layers of the deep media. Great care is taken to create a smoothly tapered transition between the endarterectomized portion of the artery and its normal distal extent. This maneuver avoids intimal flaps that might lead to arterial dissection after flow is reestablished. Some surgeons will place "tacking sutures" at the distal end of the endarterectomy to further guard against possible dissection of the distal internal carotid artery following restoration of blood flow. A variation of the procedure removes the plaque after transecting the internal carotid near its origin. (See 'Conventional versus eversion endarterectomy' below.) After meticulous inspection of the endarterectomized surface to remove any residual plaque or debris, attention is directed at repair. Some surgeons choose to repair primarily, while others patch the artery with saphenous vein or prosthetic material such as polyester (eg, Dacron), https://www.uptodate.com/contents/carotid-endarterectomy/print 15/45 7/5/23, 11:36 AM Carotid endarterectomy - UpToDate polytetrafluoroethylene (eg, Gore-Tex), or bovine pericardium. There is evidence that routine patch use lowers the risk of perioperative carotid thrombosis, stroke, and late restenosis of the endarterectomy site. (See 'Patch angioplasty versus primary closure' below.) Just prior to completion of the arterial closure, the carotid clamps are sequentially briefly released and re-clamped to back bleed (external carotid artery, internal carotid artery) and forward flush (common carotid artery) the vessel, which is then irrigated (eg, heparinized saline) and suctioned of any residual debris. After the suture line is completed, flow is restored first to the external carotid artery, then to the internal carotid artery to avoid any distal embolization to the cerebral hemisphere. A topical hemostatic agent may be used over the suture line to slow any oozing of blood. At the completion of the procedure, we suggest reversal of heparin with protamine. The only randomized trial comparing protamine with no protamine reported significantly lower rates of wound drainage but cautioned that protamine might increase the risk for thrombotic complications [85]. In a retrospective analysis of 4587 patients in a regional registry, reversal of heparin with protamine was associated with a lower incidence of serious bleeding requiring reoperation (0.64 versus 1.7 percent) compared with no reversal, without increasing the risk of myocardial infarction, stroke, or death [86]. A later systematic review that included the randomized trial, the registry study, and 10 other observational studies similarly found no significant differences for stroke (nine studies), myocardial infarction (three studies), or mortality (seven studies) for those who received protamine compared with those who did not; however, protamine use significantly decreased the risk of major bleeding complications requiring reoperation (relative risk [RR] 0.57; 95% CI 0.39-0.84; 10 studies) [87]. Dosing of heparin (fixed dosing, per body weight), dosing of protamine, and use of monitoring via activated clotting time varied across the studies and could not be adequately evaluated. A subgroup analysis suggested that stroke risk may be higher for primary carotid closure compared with patch closure when using protamine, but the overall number of events was small, limiting the ability to draw a firm conclusion. Although a small Jackson-Pratt drain can be placed, drains are generally not required and have not been shown to definitively reduce the rates of significant postoperative incisional hematomas. The platysma and skin are closed and the wound dressed. A completion study to assess the integrity of the repair can be performed intraoperatively using Doppler evaluation, duplex ultrasound, or contrast arteriogram, depending upon resources and operator preference [88-100]. A retrospective review that categorized surgeons as rarely, selectively, or routinely using completion imaging found no significant differences in perioperative stroke or death after adjustment for patient characteristics [92]. A small but https://www.uptodate.com/contents/carotid-endarterectomy/print 16/45 7/5/23, 11:36 AM Carotid endarterectomy - UpToDate significant reduction in restenosis (>70 percent) was found for surgeons who performed completion imaging. High access More distal (cranial) access may be needed. As the internal carotid artery is dissected, the hypoglossal nerve will be seen to cross anteriorly. The nerve is isolated and gently retracted. The ansa hypoglossus (ansa cervicalis) nerve, which innervates the strap muscles of the neck, is typically seen coursing along the carotid sheath. The ansa can be divided without clinically significant consequence when dissection needs to be carried more cranially. The posterior belly of the digastric muscle can also be divided. Subluxation of the jaw facilitated by nasotracheal intubation, or mandibular osteotomies, while frequently discussed, are rarely warranted. Conventional versus eversion endarterectomy Eversion endarterectomy is a variant of CEA. The internal carotid artery is transected horizontally at its origin at the carotid bulb and then the artery is everted, or turned inside out, which creates an exposure not seen with vertical arteriotomy. A modification of the technique that uses a linear incision over the common carotid artery and proximal internal carotid artery has been described [101]. Eversion endarterectomy is particularly appealing in small arteries and in patients with significant carotid redundancy as a means to eliminate carotid kinks and coils. However, in our opinion, the bulk of the evidence does not favor one technique over the other. The largest and best designed trial comparing eversion endarterectomy with conventional endarterectomy (EVEREST trial) was a multicenter trial that included 1342 patients [102]. No significant differences were found for the primary endpoints (perioperative stroke and death, carotid occlusion) or secondary endpoints (any stroke, ipsilateral stroke, transient ischemic attack, cranial nerve injury, neck hematoma, myocardial infarction). For eversion CEA compared with conventional CEA, the odds ratio for a combined endpoint of perioperative major stroke or death was 1.0 (95% CI 0.4-2.9), and for any perioperative stroke, 1.2 (95% CI 0.5-2.7). Compared with CEA performed without a patch, eversion CEA and conventional patched CEA each had a lower risk of carotid restenosis (hazard ratio [HR] 0.3, 95% CI 0.2-0.6, and HR 0.2, 95% CI 0.07-0.6, respectively). A meta-analysis that included the EVEREST trial and five other smaller trials [102- 108] identified a trend toward a reduced risk of perioperative (30 day) stroke for eversion CEA compared with conventional CEA (odds ratio [OR] 0.56, 95% CI 0.33-0.96) [109]. Randomized trials and other observational studies that have evaluated conventional versus eversion CEA have included patients with asymptomatic and symptomatic disease [102-110]. A post hoc analysis of data from the Stent-Protected Angioplasty versus Carotid Endarterectomy in Symptomatic Patients (SPACE-1) trial found no overall difference between the techniques; https://www.uptodate.com/contents/carotid-endarterectomy/print 17/45 7/5/23, 11:36 AM Carotid endarterectomy - UpToDate however, perioperative outcomes were better for conventional CEA, while later outcomes favored eversion CEA [111]. Ipsilateral stroke or death 30 days was significantly reduced for conventional versus eversion CEA (9 versus 3 percent), but the risk of ipsilateral stroke >30 days was significantly lower for eversion compared with conventional CEA (3 versus 0 percent). Interestingly, eversion CEA was not found to have a significantly lower incidence of restenosis in contrast to other studies [109,112]. Proponents of eversion CEA feel that once the technique has been mastered, it may be easier to perform than conventional CEA. Although this may be so, advocates of conventional CEA point out that shunt insertion during eversion CEA can be more difficult since the plaque must be completely removed before the shunt can be inserted. In addition, eversion CEA is less commonly introduced during vascular surgery training, and, for those who adopt it later, the technique may be associated with a learning curve. A retrospective review at an academic medical center compared the outcomes of the first 100 patients on whom they performed eversion endarterectomy with 100 patients who underwent conventional endarterectomy [113]. The rate of perioperative neurologic deficits and deaths were not significantly different. One case of amaurosis occurred after eversion CEA, and one case each of transient cerebral ischemia and retinal infarction after conventional CEA; one cardiac death occurred with each. No significant differences were seen in the rate of critical (>80 percent) residual or recurrent stenosis, late stroke, or late carotid occlusion at 36 months follow-up. However, eversion endarterectomy had a higher rate of >50 percent recurrent stenosis (38 versus 6 percent) compared with conventional CEA in spite of similar residual stenosis rates. The significance of this late mild-to-moderate stenosis is unknown. A systematic review comparing techniques found a higher risk of early postoperative hypertension for eversion endarterectomy; conventional techniques were more often associated with hypotension [114]. Patch angioplasty versus primary closure As noted above, some surgeons choose to repair to the carotid artery primarily, while others patch the artery with saphenous vein or synthetic material (eg, polytetrafluoroethylene, Dacron, bovine pericardium) [115-121]. We recommend patch closure for all patients undergoing CEA (noneversion technique). In a review of 118,711 patients undergoing CEA from the Vascular Quality Initiative, 6,668 (5.6 percent) patients had primary repair [122]. Among these patients, the rate of neurologic events was higher compared with those who underwent patch closure. Trials performed in patients undergoing CEA suggest two benefits from use of a patch: a marked reduction in the frequency of 50 percent restenosis and a lower rate of ipsilateral stroke [123,124]. A systematic review of patch angioplasty versus primary closure during CEA identified 10 trials involving 1967 patients undergoing 2157 operations [124]. Many of the trials were https://www.uptodate.com/contents/carotid-endarterectomy/print 18/45 7/5/23, 11:36 AM Carotid endarterectomy - UpToDate limited by significant methodological flaws; most were small, and none could be analyzed on a true intention-to-treat basis because of losses to follow-up. The use of a patch is associated with: Reduction in the risk of ipsilateral stroke in the perioperative period (OR 0.31, 95% CI 0.1- 0.63 and long-term OR 0.32, 95% CI 0.16-0.63). A reduced risk of perioperative arterial occlusion (OR 0.18, 95% CI 0.08-0.41). Decreased restenosis during long-term follow-up in eight trials (OR 0.24, 95% CI 0.17-0.34). These results are more certain than those of the previous review since the number of operations and events have increased. However, the sample sizes are still relatively small, data were not available from all trials, and there was significant loss to follow-up. No significant correlation was found between use of patch angioplasty and the risk of either perioperative or long-term all-cause death rates. A separate systematic review identified 14 trials comparing various types of patches: seven compared vein patch closure with polytetrafluoroethylene patch closure; five compared Dacron patches with other synthetic materials; and two compared bovine pericardium with other synthetic materials [116]. No significant differences were found comparing synthetic patches versus vein patches for stroke, death, arterial occlusion, arterial rupture, nerve palsy, wound infection, or recurrent arterial stenosis during perioperative at one-year follow-up. The review identified one high-quality trial comparing Dacron with polytetrafluoroethylene patches, reporting that Dacron patches were associated with an increased risk for perioperative stroke and an increased risk for both perioperative and late recurrent carotid stenosis [119,120]. Using a synthetic patch decreased the risk of pseudoaneurysm relative to using a vein patch (OR 0.09, 95% CI 0.02-0.49). However, the studies that examined pseudoaneurysm outcomes were older [125-127], using saphenous vein, jugular vein, or other vein sites; the technical aspects of vein handling were not included. In one of these studies, the incidence of pseudoaneurysm was 17 percent using jugular vein, 9 percent using saphenous vein or polytetrafluoroethylene, and 5 percent with primary closure [125]. The use of vein during initial CEA has declined, but when vein is needed (eg, graft infection, redo carotid surgery), we prefer to use proximal saphenous vein harvested from the groin rather than more distal vein, which is associated with rupture. A later trial comparing polytetrafluoroethylene (eg, Acuseal) with bovine pericardium also found no significant differences between these materials for ipsilateral stroke, recurrent carotid stenosis, or other perioperative complications (eg, neck hematoma); mean hemostasis time was slightly lower for the polytetrafluoroethylene patch. https://www.uptodate.com/contents/carotid-endarterectomy/print 19/45 7/5/23, 11:36 AM Carotid endarterectomy - UpToDate Very few studies have evaluated arterial complications, such as hemorrhage, infection, cranial nerve injury, or pseudoaneurysm formation for patch repair compared with primary closure, but the available data suggest no significant differences [128]. Carotid shunting If the patient demonstrates evidence of cerebral ischemia by any neuromonitoring technique, carotid shunting should be performed expeditiously if one is not already in place. For surgeons using "selective shunting," shunt placement is indicated for: Awake patients who develop agitation, slurred speech, disorientation, or extremity weakness, or the presence of theta and delta waves or disorganized rhythms on electroencephalography monitoring [129]. For patients undergoing general anesthesia, electroencephalography (raw or processed) is commonly used to monitor brain perfusion. A neuromonitoring team assesses the electroencephalography tracings for cerebral ischemia indicating the need for shunting (eg, presence of theta and delta waves or disorganized rhythms). Another method is to measure carotid stump pressures. (See 'Assessing brain perfusion' above.) In an updated Cochrane meta-analysis of three trials [130-132], compared with no shunting, the risk of perioperative stroke was lower for routine shunting (OR 0.15, 95% CI 0.03-0.78), as was the risk of ipsilateral stroke within 30 days of surgery (OR 0.41, 95% CI 0.18-0.97) and stroke- related death within 30 days of surgery (OR 0.13, 95% CI 0.02-0.96) [133]. The authors noted though that the analysis was inadequately powered to reliably detect these effects. Routine versus selective shunting Studies targeted at defining the best approach to shunting have been equivocal with respect to demonstrating any difference in important clinical outcomes when comparing routine versus selective shunting. Given that there is no consensus, the approach to shunting remains largely a matter of surgeon preference [133-135]. In an analysis of 13,469 CEAs performed for symptomatic carotid stenosis in the Vascular Quality Initiative database between 2010 to 2019, 3186 (24 percent) were performed by surgeons considered routine shunters (ie, utilization in >95 percent of cases). The overall in-hospital stroke and death rates were similar between routine shunters and selective shunters [136]. In a trial that randomly assigned 200 patients undergoing CEA to general anesthesia with routine shunting (98 patients) or selective shunting based on stump pressure, the difference in the combined outcome of perioperative transient ischemic attack or stroke rates was not statistically significant (routine shunting: 2 percent; selective shunting: 2.9 percent) as was the https://www.uptodate.com/contents/carotid-endarterectomy/print 20/45 7/5/23, 11:36 AM Carotid endarterectomy - UpToDate difference in perioperative complication rates (routine shunting: 8.3 percent; selective shunting: 7.8 percent) [137]. Proponents of selective carotid shunting argue that shunting exposes patients to risks that may include the following: Formation of an intimal flap during shunt insertion, resulting in arterial dissection Dislodgement of plaque emboli during vessel manipulation Air embolism due to bubbles in the shunt Several studies have identified factors that may increase the need for a shunt, including older age, female sex, hypertension, contralateral carotid artery occlusion, and history of contralateral carotid artery surgery [138]. Surgeons who routinely shunt feel that shunt complications are less likely to occur if shunting is routinely practiced. The advantages of routine shunting may include: Familiarity of the surgeon and surgical team with the technique. Among patients with contralateral carotid occlusion undergoing CEA, data from the Vascular Study Group of New England database reported that surgeons who routinely shunted had lower stroke rates compared with those who selectively shunted [139]. The higher rate of stroke amongst practitioners who selectively shunted may be attributable to a lack of familiarity with the procedure. Other groups have also reported a higher rate of shunting in patients with contralateral carotid occlusion [140,141]. Cerebral flow is assured with a properly placed shunt without need for neurological monitoring (electroencephalography, stump pressure, awake neurologic examination). However, it should be recognized that although routine shunting may avoid the need for intraoperative neuromonitoring, approximately 90 percent of patients would not require a shunt based on the results of neuromonitoring. In a meta-analysis that included eight studies, fewer arteries were shunted when local anesthesia was used compared with general anesthesia (15 versus 42 percent); however, the rate of stroke or death was similar [142]. Shunt type and placement There are insufficient data to support one type of carotid shunt over another. Many shunts are available for use (Argyle, Pruitt-Inahara, Brenner, Burbank, Sundt), and each has its advantages and disadvantages. The features (stiff versus flexible, inline Doppler, balloons https://www.uptodate.com/contents/carotid-endarterectomy/print 21/45 7/5/23, 11:36 AM Carotid endarterectomy - UpToDate for occlusion) and use of these shunts can be found on proprietary websites. The selection of a particular shunt is based largely on surgeon experience. Most surgeons become comfortable using one particular shunt. When a shunt is used, it is placed beyond the proximal and distal extent of the arteriotomy from the common to the internal carotid artery. Blood flows through the shunt, providing continuous cerebral perfusion during the procedure. The distal end is placed first into the internal carotid artery and the shunt back is bled to wash out any debris or air bubbles within the shunt prior to placing it into the common carotid artery and restoring antegrade cerebral perfusion. To minimize trapping debris within the shunt, it is mandatory to place the shunt in relatively disease-free segments of the internal and common carotid arteries. After shunt placement, neurologic reassessment is performed again. POSTOPERATIVE CARE Upon recovery from anesthesia, a neurologic assessment is performed and repeated every hour during recovery. Because blood pressure lability is common in the first 12 to 24 hours postoperatively, it is standard care for CEA patients to be placed in a monitored setting with an arterial line in place. Systolic blood pressure should be maintained between 100 to 150 mmHg in the postoperative period to prevent complications related to hypertension (eg, neck hematoma) or hypotension (eg, cerebral ischemia). (See "Anesthesia for carotid endarterectomy and carotid stenting", section on 'Blood pressure control'.) Minor headache is common following CEA, but increasing or severe headache in the postoperative period may be an indicator of cerebral hyperperfusion syndrome or intracranial hemorrhage and should be evaluated with a computed tomographic scan. (See "Complications of carotid endarterectomy", section on 'Hyperperfusion syndrome'.) PERIOPERATIVE MORBIDITY AND MORTALITY While a number of controlled trials have highlighted the patient population most likely to benefit from CEA, this operation is not without risk [143]. (See "Management of symptomatic carotid atherosclerotic disease", section on 'Patients appropriate for CEA'.) Perioperative mortality associated with CEA ranges from <0.5 to 4.3 percent and may be higher when this procedure is performed at nontertiary care centers [1,144-146]. Surgeons are encouraged to keep accurate records of their individual stroke rates to ensure that standards are upheld. Low patient volume (<3 CEAs performed every two years) and a greater number of https://www.uptodate.com/contents/carotid-endarterectomy/print 22/45 7/5/23, 11:36 AM Carotid endarterectomy - UpToDate years since licensure of the surgeon are associated with worse outcomes following CEA [147,148]. In experienced hands, the risk of stroke associated with CEA is generally 2 percent or less. However, certain anatomic and physiologic high-risk criteria are associated with worse clinical outcomes for CEA. In a review of 6370 patients undergoing CEA in the Society for Vascular Surgery Vascular Registry, high-risk patients had a higher rate of composite death, stroke, and myocardial infarction compared with normal anatomic or physiologic risk patients (symptomatic: 7.3 versus 4.6 percent; asymptomatic: 5 versus 2.2 percent) [149]. In another review of 25,788 patients undergoing CEA in the American College of Surgeons National Surgical Quality Improvement Program, 30-day stroke/death rates were significantly higher in physiologic high-risk (4.6 percent) and anatomic high-risk (3.6 percent) patients compared with normal-risk patients (2.3 percent) [150]. In a review of the Vascular Quality Initiative that included all who underwent from 2013 to 2016, patients were stratified as being normal or high risk for undergoing CEA based on criteria set forth by the US Centers for Medicare and Medicaid Services [151]. Among over 44,000 patients who underwent CEA, perioperative stroke occurred in 1.0 percent in normal-risk and 1.4 percent in high-risk patients. At two years, stroke occurred in 1.9 percent in normal-risk and 2.4 percent in high-risk patients. A retrospective review of the United States Medicare database evaluated outcomes of 454,717 CEA and 27,943 carotid artery stenting patients before and after the 2005 National Coverage Determination to reimburse carotid artery stenting for Medicare beneficiaries [148]. CEA rates declined from 18.1 to 12.7 per 10,000 beneficiaries between 2002 and 2008 (overall rates also declined). Even though patients undergoing CEA in later years were older and had more comorbidities compared with earlier years, perioperative (30 day) mortality declined from 1.4 to 1.17 percent. In a later systematic review of only large (>1000 participants each) observational cohort studies, the composite risk of procedural stroke/death among over 130,000 patients undergoing CEA decreased from before 2005 compared with from 2005 onward for symptomatic patients and asymptomatic patients (5.1 versus 2.7 percent and 3.2 versus 1.5 percent, respectively) [152]. By comparison, procedural stroke/death rates for carotid artery stenting did not change significantly over time (symptomatic: 4.8 percent; asymptomatic: 2.6 percent). For studies that reported stroke alone or death alone, no differences were seen from before 2005 compared with from 2005 onward for either procedure. The authors speculated that a trend toward https://www.uptodate.com/contents/carotid-endarterectomy/print 23/45 7/5/23, 11:36 AM Carotid endarterectomy - UpToDate centralization of CEA in high-volume centers, and specialist support, may have contributed to the decrease in CEA procedural risks. Complications associated with CEA include perioperative events such as myocardial infarction; stroke; hyperperfusion syndrome; nerve injury; parotitis and bleeding, which can lead to neck hematoma requiring reoperation; and late carotid restenosis. These complications are discussed in detail elsewhere. (See "Complications of carotid endarterectomy".) FOLLOW-UP CARE Following CEA, patients are typically discharged within one to three days. The most common cause of delay in discharge is difficulty controlling blood pressure. Control of blood pressure prior to performing CEA cannot be overemphasized. We follow up with the patient at one month postoperatively, at which time we also obtain a carotid duplex study. If there are any wound- related issues or other problems, arrangements should be made to see the patient sooner. Readmission following CEA is relatively high. In a review that included 235,247 patients undergoing carotid intervention, 8.8 percent of the patients undergoing CEA required readmission, which was lower compared with carotid artery stenting [153]. Significant factors that increased the likelihood of readmission included age >80 years (odds ratio [OR] 1.25, 95% CI 1.20-1.30), renal failure (OR 1.6, 95% CI 1.56-1.73), heart failure (OR 1.6, 95% CI 1.57-1.73), and diabetes (OR 1.4, 95% CI 1.27-1.52). A separate review of data from 2005 to 2010 from the National Surgical Quality Improvement Program found that 33 percent of strokes, 53 percent of deaths, and 32 percent of cardiac events occurred after hospital discharge [154]. Care of the incision The postoperative dressing is removed on the first postoperative day. If a drain has been placed, it should be removed as soon as possible in the postoperative period (day 1 or 2) to decrease the potential for wound infection provided there is no significant drainage. Antibiotics are limited to perioperative prophylaxis. (See 'Prophylactic antibiotics' above.) Duplex surveillance Repeat duplex ultrasonography should be obtained three to six weeks following CEA to establish a new baseline for future comparison. Duplex surveillance is performed at six months and annually. More frequent intervals may be warranted if a contralateral stenosis is being observed. (See "Complications of carotid endarterectomy", section on 'Carotid restenosis'.) SOCIETY GUIDELINE LINKS https://www.uptodate.com/contents/carotid-endarterectomy/print 24/45 7/5/23, 11:36 AM Carotid endarterectomy - UpToDate Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Occlusive carotid, aortic, renal, mesenteric, and peripheral atherosclerotic disease".) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." th th The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more th th sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.) Basics topics (see "Patient education: Carotid artery disease (The Basics)") SUMMARY AND RECOMMENDATIONS Carotid endarterectomy The effectiveness of carotid endarterectomy (CEA) for moderate-to-severe asymptomatic or symptomatic carotid artery stenosis has been established in large, randomized trials. CEA in patients with asymptomatic carotid stenosis prior to cardiac or general surgery has no demonstrated benefit. For patients with indications for bilateral CEA, a staged rather than combined procedure is performed. (See "Management of symptomatic carotid atherosclerotic disease" and "Management of asymptomatic extracranial carotid atherosclerotic disease" and 'Introduction' above and 'Carotid atherosclerotic disease' above.) Preoperative imaging Prior to CEA for asymptomatic carotid stenosis, duplex ultrasound may be sufficient to reliably determine the degree of internal carotid artery stenosis and assess local anatomy when performed in a certified vascular laboratory using validated criteria. If these standards cannot be met, additional vascular imaging to verify the degree of stenosis should be performed. (See 'Carotid duplex' above.) https://www.uptodate.com/contents/carotid-endarterectomy/print 25/45 7/5/23, 11:36 AM Carotid endarterectomy - UpToDate Antiplatelet therapy Prior to CEA, we recommend starting aspirin (81 to 325 mg daily) and continuing treatment indefinitely (Grade 1B). For patients who are sensitive to aspirin, clopidogrel is an alternative agent. (See 'Antiplatelet therapy' above.) Statin therapy For patients with symptomatic carotid stenosis, we suggest initiation of statin therapy prior to CEA (or maintenance in patients already being treated) (Grade 2B). The use of statins in symptomatic patients is associated with reduced morbidity and mortality following CEA. For patients with asymptomatic carotid stenosis undergoing CEA, statin therapy has not shown the same benefit but may be indicated for other medical reasons. (See 'Statins' above.)