Early and Long‐Term Outcomes of Carotid Endarterectomy in Patients With Carotid Near‐Occlusion Versus Preocclusive Carotid Stenosis

BACKGROUND: The clinical role of carotid endarterectomy (CEA) in patients with carotid near-occlusion (CNO) remains a subject of ongoing debate, and comparative data regarding its long-term efficacy versus preocclusive carotid stenosis is limited. This study aimed to evaluate and compare the perioperative and long-term outcomes of CEA in these two distinct subsets of high-grade carotid disease. METHODS: A retrospective analysis was conducted on a prospectively maintained database of 1775 consecutive CEAs performed at a single center between January 2014 and September 2025. The study cohort included 81 procedures for CNO (Group 1) and 144 for preocclusive carotid stenosis > 95% with distal lumen recovery (Group 2). CNO was defined by distal internal carotid artery caliber reduction and further stratified by the presence of full distal collapse. RESULTS: Results showed that patients in Group 2 were significantly older than those in Group 1 (76 ± 8 vs. 72 ± 8 years; p < 0.001). Symptomatic presentation was more frequent in Group 1 (35.8% vs. 24.3%; p = 0.06), and concordant ipsilateral ischemic brain lesions were significantly more common in CNO patients (24.5% vs. 9%; p = 0.001). Regarding perioperative safety, no 30-day deaths or major neurologic events occurred in Group 1, while Group 2 had a 30-day stroke/death rate of 3.4% (p = 0.08 vs. Group 1). During a median follow-up of 30 months (range 1-140), the estimated 6-year overall survival was 84% for Group 1% and 73% for Group 2 (p = 0.1). Notably, ipsilateral stroke at 6 years occurred in 0% of CNO patients compared with 8.5% in the preocclusive group (p = 0.03). Stroke-free survival at 6 years was 84% in Group 1% and 71% in Group 2 (p = 0.09). While freedom from restenosis was comparable (78.5% vs. 86.3%; p = 0.2), late carotid occlusion was significantly more frequent in the CNO group (6% vs. 0%; p = 0.02). CONCLUSIONS: In this single-center series, patients undergoing CEA for carotid near-occlusion demonstrated favorable perioperative safety and a lower observed incidence of long-term ipsilateral stroke during follow-up compared with those treated for preocclusive stenosis, even in the presence of full distal collapse. The absence of a medically managed control group and the small number of events made these findings hypothesis-generating. However, the higher incidence of late restenosis and occlusion in near-occlusion highlights the importance of a personalized, intensified postoperative surveillance, particularly for patients with full distal collapse.