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.) Antibiotic prophylaxis We recommend antibiotic prophylaxis prior to CEA to reduce the risk of surgical site infection due to the frequent use of prosthetic material (Grade 1B). Antibiotics should be discontinued within 24 hours. (See 'Prophylactic antibiotics' above.) Anesthesia CEA can be performed using general anesthesia or local anesthesia (with or without cervical block). Statistically significant differences for major endpoints (perioperative stroke, myocardial infarction, and death) have not been consistently shown for differing anesthetic approaches. The choice of anesthetic technique is largely dependent on the preferences of the patient, the anesthesiologist, and the surgeon. (See 'Anesthesia' above.) Carotid endarterectomy technique No one technique for plaque removal has been found to be superior over another with respect to the incidence of stroke, death, or other morbidity. As with many surgical techniques, one technique may be preferable to another for specific circumstances, and the choice of technique is largely dependent on the preferences and experience of the surgeon. (See 'Endarterectomy procedure' above and 'Conventional versus eversion endarterectomy' above.) Prior to carotid artery clamping, the patient is systemically anticoagulated, typically using heparin. At the completion of the procedure, we suggest reversal of heparin with protamine over no reversal (Grade 2B). (See 'General conduct of operation' above.) Following carotid plaque removal, we recommend patch closure of the carotid artery over no patch (noneversion technique) (Grade 1B). With conventional CEA, carotid patch techniques are associated with decreased rates of stroke and carotid restenosis. No one patch material (synthetic, vein, bovine pericardium) has been shown to be superior over another. (See 'Patch angioplasty versus primary closure' above.) https://www.uptodate.com/contents/carotid-endarterectomy/print 26/45 7/5/23, 11:36 AM Carotid endarterectomy - UpToDate Postoperative care After the completion of the procedure, the patient's neurologic status and blood pressure are carefully monitored. We keep the systolic blood pressure between 100 and 150 mmHg. Hypotension and hypertension are both associated with adverse outcomes. (See 'Postoperative care' above.) Perioperative morbidity and mortality The perioperative mortality associated with CEA ranges from <0.5 to 3 percent. Complications associated with CEA include perioperative complications such as myocardial infarction; stroke; hyperperfusion syndrome; nerve injury; parotitis and bleeding, which can lead to neck hematoma requiring reoperation; and late carotid restenosis. (See 'Perioperative morbidity and mortality' above and "Complications of carotid endarterectomy".) ACKNOWLEDGMENTS The editorial staff at UpToDate acknowledges Ronald M Fairman, MD, who contributed to an earlier version of this topic review. The editorial staff also acknowledges Emile R Mohler, III, MD (deceased), who contributed to an earlier version of this topic. UpToDate also wishes to acknowledge Dr. Mohler's work as our Section Editor for Vascular Medicine. Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Knappich C, Kuehnl A, Haller B, et al. 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