Carotid artery disease occurs when plaque, fatty deposits, builds up within the carotid arteries in the neck. These arteries supply blood to the brain. This buildup, known as atherosclerosis, narrows the arteries, restricting blood flow and increasing stroke risk. A stroke happens when blood flow to the brain is interrupted, causing brain cell death. Transient ischemic attacks (TIAs), or “mini-strokes,” can also occur as a warning sign. To address this, two main procedures are used: carotid endarterectomy (CEA) and carotid artery stenting (CAS). Both aim to clear blockages, restore blood flow, and reduce stroke risk.
The Surgical Approach: Carotid Endarterectomy
Carotid endarterectomy (CEA) is an open surgical procedure that removes plaque from the carotid artery. It can be performed under general or local anesthesia. A surgeon makes an incision, typically a few inches long, along the front of the neck to access the affected artery.
The artery is temporarily clamped to halt blood flow, then opened. Plaque is scraped away from the arterial wall. A temporary shunt may be used to maintain blood flow to the brain during this process. After plaque removal, the artery is stitched closed, often with a patch from a vein or synthetic material to widen it and prevent future narrowing. The neck incision is then closed with sutures or staples. The procedure generally takes one to two hours.
The Minimally Invasive Option: Carotid Artery Stenting
Carotid artery stenting (CAS) is a less invasive treatment for carotid artery disease. The procedure begins with a puncture, usually in the groin, where a catheter is inserted into an artery. The catheter is then carefully guided using X-ray imaging to the narrowed carotid artery in the neck.
Before widening the artery, an embolic protection device, a small filter, is deployed beyond the blockage. This device captures any plaque or debris that might break off, preventing it from traveling to the brain. A balloon catheter is then advanced to the narrowed area, inflated to push plaque against the artery walls, then deflated and removed. Finally, a permanent metal mesh tube, or stent, is placed to keep the artery open and maintain blood flow to the brain.
Comparing Procedure Outcomes and Risks
Comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS) highlights differences in outcomes and risks. The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) provides key data. CREST found a higher periprocedural stroke risk with CAS (4.1%) compared to CEA (2.3%), with most CAS-related strokes being minor. However, some studies on symptomatic patients reported higher 30-day rates of stroke or death after CAS than CEA.
Conversely, CEA carries a higher periprocedural risk of heart attack. CREST data showed myocardial infarction in 2.3% of CEA patients versus 1.1% for CAS patients. While one meta-analysis showed a 30-day absolute risk of myocardial infarction at 0.87% for CEA and 0.70% for CAS, the difference was not statistically significant.
Local complications vary. CEA, as open surgery, risks include cranial nerve injury (e.g., facial, vagus, hypoglossal nerves), potentially affecting voice or swallowing. Incision-site infection or hematoma in the neck are also risks. CAS complications can include groin hematoma, pseudoaneurysm at the puncture site, or, rarely, acute stent thrombosis or cerebral hyperperfusion syndrome.
Recovery is generally faster with CAS, often requiring only an overnight hospital stay. CEA, involving a neck incision, typically requires a longer hospital stay and recovery period. Long-term durability, including restenosis rates, has shown comparable outcomes between the two procedures over many years, supported by 10-year follow-up data from trials like CREST.
Determining Candidate Suitability
The choice between carotid endarterectomy (CEA) and carotid artery stenting (CAS) involves a thorough assessment of individual patient factors and the characteristics of the carotid artery blockage. Carotid endarterectomy is generally considered for younger, healthier patients whose anatomy is well-suited for open surgery. This procedure is often recommended for symptomatic patients with a significant stenosis, typically between 50% and 99% (ideally 70-99%), who have experienced recent transient ischemic attacks or non-disabling strokes. For asymptomatic patients, CEA may be considered if they have a stenosis of 60% to 99%, a life expectancy exceeding five years, and a low anticipated surgical risk.
Carotid artery stenting is frequently recommended for patients who face higher risks associated with open surgery. This includes older individuals, particularly those over 75 or 80 years of age, who may have increased periprocedural risks with CEA. Patients with severe underlying medical conditions, such as significant heart or lung disease like Class III/IV congestive heart failure, a low left ventricular ejection fraction (below 30%), or a recent myocardial infarction, are often better candidates for CAS.
Additional anatomical factors can influence the choice. CAS is preferred for those with a “hostile neck” due to prior neck surgery or radiation therapy, which can complicate open surgical access. Patients with a complete blockage of the carotid artery on the opposite side, or blockages located in areas difficult to reach surgically, are also more suitable for stenting. Furthermore, CAS is often utilized for patients who experience restenosis, or re-narrowing, of the artery after previously undergoing a CEA.