endarterectomy. North American Symptomatic Carotid Endarterectomy Trial (NASCET). Stroke 1999; 30:1759. 40. Ferguson GG, Eliasziw M, Barr HW, et al. The North American Symptomatic Carotid Endarterectomy Trial : surgical results in 1415 patients. Stroke 1999; 30:1751. 41. Vasconcelos V, Cassola N, da Silva EM, Baptista-Silva JC. Immediate versus delayed treatment for recently symptomatic carotid artery stenosis. Cochrane Database Syst Rev 2016; 9:CD011401. 42. De Rango P, Brown MM, Chaturvedi S, et al. Summary of Evidence on Early Carotid Intervention for Recently Symptomatic Stenosis Based on Meta-Analysis of Current Risks. Stroke 2015; 46:3423. https://www.uptodate.com/contents/management-of-symptomatic-carotid-atherosclerotic-disease/print 23/34 7/5/23, 11:41 AM Management of symptomatic carotid atherosclerotic disease - UpToDate 43. Rerkasem K, Rothwell PM. Systematic review of the operative risks of carotid endarterectomy for recently symptomatic stenosis in relation to the timing of surgery. Stroke 2009; 40:e564. 44. Blaisdell WF, Clauss RH, Galbraith JG, et al. Joint study of extracranial arterial occlusion. IV. A review of surgical considerations. JAMA 1969; 209:1889. 45. BRUETMAN ME, FIELDS WS, CRAWFORD ES, DEBAKEY ME. CEREBRAL HEMORRHAGE IN CAROTID ARTERY SURGERY. Arch Neurol 1963; 9:458. 46. Rob CG. Operation for acute completed stroke due to thrombosis of the internal carotid artery. Surgery 1969; 65:862. 47. Pritz MB. Timing of carotid endarterectomy after stroke. Stroke 1997; 28:2563. 48. Chaturvedi S, Bruno A, Feasby T, et al. Carotid endarterectomy an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005; 65:794. 49. McPherson CM, Woo D, Cohen PL, et al. Early carotid endarterectomy for critical carotid artery stenosis after thrombolysis therapy in acute ischemic stroke in the middle cerebral artery. Stroke 2001; 32:2075. 50. Bartoli MA, Squarcioni C, Nicoli F, et al. Early carotid endarterectomy after intravenous thrombolysis for acute ischaemic stroke. Eur J Vasc Endovasc Surg 2009; 37:512. 51. Crozier JE, Reid J, Welch GH, et al. Early carotid endarterectomy following thrombolysis in the hyperacute treatment of stroke. Br J Surg 2011; 98:235. 52. Bazan HA, Zea N, Jennings B, et al. Urgent carotid intervention is safe after thrombolysis for minor to moderate acute ischemic stroke. J Vasc Surg 2015; 62:1529. 53. Brinster CJ, Sternbergh WC 3rd. Safety of urgent carotid endarterectomy following thrombolysis. J Cardiovasc Surg (Torino) 2020; 61:149. 54. Vellimana AK, Washington CW, Yarbrough CK, et al. Thrombolysis is an Independent Risk Factor for Poor Outcome After Carotid Revascularization. Neurosurgery 2018; 83:922. 55. Rantner B, Kollerits B, Roubin GS, et al. Early Endarterectomy Carries a Lower Procedural Risk Than Early Stenting in Patients With Symptomatic Stenosis of the Internal Carotid Artery: Results From 4 Randomized Controlled Trials. Stroke 2017; 48:1580. 56. Coelho A, Peixoto J, Mansilha A, et al. Editor's Choice - Timing of Carotid Intervention in Symptomatic Carotid Artery Stenosis: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2022; 63:3. 57. Cui CL, Dakour-Aridi H, Eldrup-Jorgensen J, et al. Effects of timing on in-hospital and one- year outcomes after transcarotid artery revascularization. J Vasc Surg 2021; 73:1649. https://www.uptodate.com/contents/management-of-symptomatic-carotid-atherosclerotic-disease/print 24/34 7/5/23, 11:41 AM Management of symptomatic carotid atherosclerotic disease - UpToDate 58. Elmously A, Rich N, Lazar AN, et al. Outcomes of early transcarotid artery revascularization versus carotid endarterectomy after acute neurologic events. J Vasc Surg 2022; 76:760. 59. de Borst GJ, Hazenberg CE. How should I treat a patient with a tandem carotid artery atherosclerotic stenosis involving the internal carotid artery and the innominate/proximal common carotid artery? Eur J Vasc Endovasc Surg 2015; 50:257. 60. Chung J, Valentine W, Sharath SE, et al. Percutaneous intervention for carotid in-stent restenosis does not improve outcomes compared with nonoperative management. J Vasc Surg 2016; 64:1286. Topic 1106 Version 43.0 https://www.uptodate.com/contents/management-of-symptomatic-carotid-atherosclerotic-disease/print 25/34 7/5/23, 11:41 AM Management of symptomatic carotid atherosclerotic disease - UpToDate GRAPHICS Lateral view of the internal carotid artery Lateral view of a schematic drawing of the carotid arteries, vertebral arteries, and intracranial vessels and their relationships in the neck and brain. Reproduced with permission from: U acker R. Atlas Of Vascular Anatomy: An Angiographic Approach, Second Edition. Philadelphia: Lippincott Williams & Wilkins, 2007. Copyright 2007 Lippincott Williams & Wilkins. Graphic 63286 Version 1.0 https://www.uptodate.com/contents/management-of-symptomatic-carotid-atherosclerotic-disease/print 26/34 7/5/23, 11:41 AM Management of symptomatic carotid atherosclerotic disease - UpToDate Methods of measuring carotid stenosis in NASCET and ECST Modi ed from Donnan, GA, Davis, SM, Chambers, BR, Gates, PC, Lancet 1998; 351:1372. NASCET: North American Symptomatic Carotid Endarterectomy Trial; ECST: European Carotid Surgery Trial; CC: Common Carotid Method. Graphic 58353 Version 2.0 https://www.uptodate.com/contents/management-of-symptomatic-carotid-atherosclerotic-disease/print 27/34 7/5/23, 11:41 AM Management of symptomatic carotid atherosclerotic disease - UpToDate Benefit of carotid endarterectomy after recent ipsilateral nondisabling stroke or TIA in the NASCET trial The NASCET included 659 patients with a recent TIA or nondisabling stroke and a 70 to 99 percent carotid stenosis who were randomly assigned to carotid endarterectomy or medical therapy. After a two- year follow-up, the cumulative risk of any ipsilateral stroke was significantly lower in the endarterectomy group compared with the medical treatment group (9 versus 26 percent). The Kaplan-Meier survival curve shows the probability of event-free survival after randomization at six-month intervals. NASCET: North American Symptomatic Carotid Endarterectomy Trial; TIA: transient ischemic attack. Data from: North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1991; 325:445. Graphic 75669 Version 7.0 https://www.uptodate.com/contents/management-of-symptomatic-carotid-atherosclerotic-disease/print 28/34 7/5/23, 11:41 AM Management of symptomatic carotid atherosclerotic disease - UpToDate Carotid endarterectomy reduces major stroke and death in symptomatic patients with severe stenosis The NASCET included 659 patients with a recent TIA or nondisabling stroke and a 70 to 99 percent carotid stenosis who were randomly assigned to carotid endarterectomy or medical therapy. At two-year follow-up, the cumulative risk of a major stroke or death was significantly lower in the endarterectomy group compared with the medical treatment group (8.0 versus 19.1 percent). The Kaplan- Meier survival curve shows the probability of event-free survival after randomization at six-month intervals. NASCET: North American Symptomatic Carotid Endarterectomy Trial; TIA: transient ischemic attack. Data from: North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1991; 325:445. Graphic 67964 Version 12.0 https://www.uptodate.com/contents/management-of-symptomatic-carotid-atherosclerotic-disease/print 29/34 7/5/23, 11:41 AM Management of symptomatic carotid atherosclerotic disease - UpToDate Sex difference in the effect of time from symptoms to surgery on benefit from c endarterectomy for TIA and nondisabling stroke Pooled data from the NASCET and the ECST showing the absolute reduction with surgery in the five-year risk each of the three main trial outcomes (ie, time to first ipsilateral ischemic stroke and any perioperative stroke death) in patients with 50 to 69% carotid artery stenosis (light bars) and 70% carotid artery stenosis withou occlusion (dark bars), stratified by the time from last symptomatic event to randomization and sex. The numb adjacent to the bars indicate the exact absolute risk reduction (ARR). TIA: transient ischemic attack; NASCET: North American Symptomatic Carotid Endarterectomy Trial; ECST: Eu Carotid Surgery Trial. https://www.uptodate.com/contents/management-of-symptomatic-carotid-atherosclerotic-disease/print 30/34 7/5/23, 11:41 AM Management of symptomatic carotid atherosclerotic disease - UpToDate From: Rothwell PM, Eliasziw M, Gutnikov SA, et al. Sex di erence in the e ect of time from symptoms to surgery on bene t from carotid endarterectomy for transient ischemic attack and nondisabling stroke. Stroke 2004; 35:2855. DOI: 10.1161/01.STR.0000147040.20446. Copyright 2004 American Heart Association. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of material is prohibited. Graphic 131304 Version 1.0 https://www.uptodate.com/contents/management-of-symptomatic-carotid-atherosclerotic-disease/print 31/34 7/5/23, 11:41 AM Management of symptomatic carotid atherosclerotic disease - UpToDate Predicted five-year risk of ipsilateral ischemic stroke in patients with recently symptomatic carotid stenosis on medical treatment Derived from Cox model based on five clinically important patient characteristics in men and women. Stroke/TIA/Ocular refers to the most severe symptomatic ipsilateral ischemic event in the past six months: Stroke> Cerebral TIA> Ocular events only. Reproduced with permission from: Rothwell, PM, Mehta, Z, Howard, SC, et al. From subgroups to individuals: general principles and the example of carotid endarterectomy. Lancet 2005; 365:256. Copyright 2005 Elsevier. Graphic 71761 Version 1.0 https://www.uptodate.com/contents/management-of-symptomatic-carotid-atherosclerotic-disease/print 32/34 7/5/23, 11:41 AM Management of symptomatic carotid atherosclerotic disease - UpToDate Early carotid endarterectomy is associated with improved outcomes Shown is the absolute reduction with surgery in the five-year cumulative risk of ipsilateral carotid ischemic stroke and any stroke or death within 30 days after carotid endarterectomy (CEA) in patients with 50 to 69 percent stenosis and 70 percent stenosis without near occlusion stratified by the time from last symptomatic event to randomization. Numbers above the bars indicate actual absolute risk reduction. Vertical bars are 95 percent confidence intervals. These results suggest that CEA is likely to be of greatest benefit if performed within two weeks of the last neurologic event in patients with 70 percent carotid stenosis. For patients with 50 to 69 percent stenosis, CEA may only have benefit if performed within two weeks of the last event. Data from: Rothwell PM, Eliasziw M, Gutnikov SA, et al. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004; 363:915. Graphic 70338 Version 3.0 https://www.uptodate.com/contents/management-of-symptomatic-carotid-atherosclerotic-disease/print 33/34 7/5/23, 11:41 AM Management of symptomatic carotid atherosclerotic disease - UpToDate Contributor Disclosures Michael T Mullen, MD Grant/Research/Clinical Trial Support: NINDS [Asymptomatic carotid disease]. All of the relevant financial relationships listed have been mitigated. Jeffrey Jim, MD, MPHS, FACS Consultant/Advisory Boards: Endospan [Aortic interventions]; Medtronic [Aortic interventions]; Silk Road Medical [Carotid stent]. All of the relevant financial relationships listed have been mitigated. Scott E Kasner, MD Grant/Research/Clinical Trial Support: Bayer [Stroke]; Bristol Meyers Squibb [Stroke]; Medtronic [Stroke]; WL Gore and Associates [Stroke]. Consultant/Advisory Boards: Abbvie [Stroke]; AstraZeneca [Stroke]; BMS [Stroke]; Diamedica [Stroke]; Medtronic [Stroke]. All of the relevant financial relationships listed have been mitigated. John F Eidt, MD Grant/Research/Clinical Trial Support: Syntactx [Clinical events, data/safety monitoring for medical device trials]. All of the relevant financial relationships listed have been mitigated. Joseph L Mills, Sr, MD No relevant financial relationship(s) with ineligible companies to disclose. John F Dashe, MD, PhD No relevant financial relationship(s) with ineligible companies to disclose. Kathryn A Collins, MD, PhD, FACS No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/management-of-symptomatic-carotid-atherosclerotic-disease/print 34/34