High-Risk Carotid Endarterectomy

“High-risk” carotid endarterectomy (CEA): fact or fiction? To answer this question we reviewed the available evidence starting from controlled randomized trials, through retrospective population- and large institution-based studies to case-series. CEA can be performed in most “high-risk” patients with low mortality and morbidity. A broad concept of high-risk CEA, based merely on exclusion from previous controlled randomized CEA trials, cannot be justified. The vast majority of evidence suggests that age (≥80 years) per se should not be considered a high-risk criterion for CEA. However, it appears that there are certain individual risk factors, which may influence outcome adversely. It appears that CEA in the setting of contralateral carotid occlusion may be associated with very slightly increased risk of adverse perioperative events. Local risk factors, namely carotid reoperation and CEA following prior cervical radiation therapy, are associated with slightly increased stroke, death and probably cranial nerve injury rates. If these risk factors are frequent in a particular series the overall outcome of CEA will be worse. In the absence of level-one evidence on the long-term efficacy of carotid artery stenting (CAS) in stroke prophylaxis, selection for CAS should be restricted to well-defined high-risk categories, such as severe medical comorbidities or local-anatomic risk factors.