Carotid Endarterectomy

Carotid endarterectomy (CEA) is the gold standard surgical treatment for symptomatic carotid stenosis. Landmark trials established its efficacy: NASCETNorth American Symptomatic Carotid Endarterectomy Trial (NASCET) (1991) demonstrated that [[CEA]]CEA reduced stroke risk in patients with symptomatic stenosis ≥70% [@nejm1991], and ECSTEuropean Carotid Surgery Trial (ECST) (1998) confirmed this benefit [@rothwell1998]. Beyond clinical efficacy, CEA remains more cost-effective than carotid artery stenting (CAS) in most clinical scenarios [@akkara2025]. In asymptomatic patients, ACASAsymptomatic Carotid Atherosclerosis Study (ACAS) (1995) and ACSTAsymptomatic Carotid Surgery Trial (ACST) (2004) showed a small benefit for stenosis ≥60%, though this advantage is less pronounced with modern medical therapy.

[[CEA]]CEA is recommended for symptomatic stenosis of 50–99% when performed within 14 days of transient ischemic attack (TIA) or non-disabling stroke, provided the perioperative stroke or death risk is <6% [@esvs2023].[@society2021; @esvs2023]. In asymptomatic carotid stenosis (ACS), routine [[CEA]]CEA is not indicated. However, it may be considered in highly selected patients with ≥60% stenosis who have a life expectancy >3–5 years, low perioperative risk (<3%), and high-risk imaging features [@esvs2023].[@society2021; @esvs2023].

Acceptable perioperative complication rates are crucial: <6% stroke or death for symptomatic patients and <3% for asymptomatic patients.patients [@society2021].