Indication for Carotid Endarterectomy

From recent randomized studies, carotid endarterectomy (CEA) is highly beneficial to the patients with a symptomatic high-grade carotid artery stenosis (70-99%), but the surgical indication for an asymptomatic carotid artery disease remains unsolved. Sixty-three atheromatous plaques (symptomatic 51, asymptomatic 12) were obtained from 57 patients who underwent CEA. The presence of an intraplaque hemorrhage was noted in 75% from symptomatic plaques, compared with 33% from asymptomatic ones. A plaque disruption occurred over protruding mounds of intraplaque hemorrhage and was noted in 76% and 42% from symptomatic and asymptomatic ones, respectively. However, asymptomatic plaques, which were angiographically demonstrated as carotid ulcer of types B and C, had a high incidence of intraplaque hemorrhage as well as plaque disruption. Three patients followed with asymptomatic contralateral carotid artery disease developed a stroke following ipsilateral revascularization and all three specimens showed the presence of plaque hemorrhage and disruption. It is concluded that before prophylactic CEA is considered, an intraplaque hemorrhage and/or plaque disruption should be detected by less invasive procedures such as ultrasonography.