Indications for carotid endarterectomy: stenosis grade or nature of the plaque

Objective. To determine the feasibility of expanding the indications through assessment of plaque structure and morphology. Material and methods. A retrospective analysis included 95 clinical cases of 50—85% internal carotid artery stenosis with symptomatic events (transient ischemic attack and ischemic stroke). Adverse events were recorded in 12 (13%) patients. The NASCET stenosis grade, CT density of the plaque, MR signs of ulceration and intraplaque hemorrhage, as well as Plaque-RADS category were assessed. Results. Stenosis grade alone did not differentiate between symptomatic and asymptomatic patients (median 66% vs 65%, p=0.646), whereas CT HUs, Plaque-RADS category and plaque ulceration were significantly associated with neurological symptoms. Low plaque density (<60 HU) was associated with events (12/57 vs 0/38; p=0.001), and Plaque-RADS 4 was associated with the highest risk (7/18 vs 5/77; OR 9.16; p=0.001). According to ROC analysis, AUC was 0.54 for NASCET, 0.80 for CT HU, 0.80 for Plaque-RADS and 0.84 for combined model CT HU+plaque ulceration. Conclusion. Plaque morphology along with stenosis grade and neurological symptoms should be considered regarding the indications for carotid endarterectomy.