Carotid Endarterectomy: Current Concepts and Practice Patterns

Abstract

Background Stroke is the number one cause of disability and third leading cause of death among adults in the United States. A major cause of stroke is carotid artery stenosis (CAS) caused by atherosclerotic plaques. Randomized trials have varying results regarding the equivalence and perioperative complication rates of stents versus carotid endarterectomy (CEA) in the management of CAS.

Objectives We review the evidence for the current management of CAS and describe the current concepts and practice patterns of CEA.

Methods A literature search was conducted using PubMed to identify relevant studies regarding CEA and stenting for the management of CAS.

Results The introduction of CAS has led to a decrease in the percentage of CEA and an increase in the number of CAS procedures performed in the context of all revascularization procedures. However, the efficacy of stents in patients with symptomatic CAS remains unclear because of varying results among randomized trials, but the perioperative complication rates exceed those found after CEA.

Conclusions Vascular surgeons are uniquely positioned to treat carotid artery disease through medical therapy, CEA, and stenting. Although data from randomized trials differ, it is important for surgeons to make clinical decisions based on the patient. We believe that CAS can be adopted with low complication rate in a selected subgroup of patients, but CEA should remain the standard of care. This current evidence should be incorporated into practice of the modern vascular surgeon.

Keywords

carotid artery disease - stroke - carotid artery stenosis - atherosclerosis - carotid endarterectomy - carotid artery stents - endovascular carotid

• References

• 1 Centers for Disease Control and Prevention (CDC). Prevalence of disabilities and associated health conditions among adults—United States, 1999. MMWR Morb Mortal Wkly Rep 2001; 50 (7) 120-125 [Erratum in: MMWR Morb Mortal Wkly Rep 2001;50(8):149]
• 2 Fairhead JF, Rothwell PM. The need for urgency in identification and treatment of symptomatic carotid stenosis is already established. Cerebrovasc Dis 2005; 19 (6) 355-358
• 3 Hunt JR. Hunt: the role of the carotid arteries: the role of the carotid arteries, in the causation of vascular lesions of the brain, with remarks on certain special features of the symptomatology. 1914. Am J Med Sci 2013; 346 (6) 504-509
• 4 Fisher M. Occlusion of the internal carotid artery. AMA Arch Neurol Psychiatry 1951; 65 (3) 346-377
• 5 Moniz E. Moniz E. L'encephalographie arterielle, son importance dans la localization des tumeurs cerebrales. Rev Neurol (Paris) 1927; 2: 72-90
• 6 Carrea RMM, Murphy G. Surgical treatment of spontaneous thrombosis of the internal carotid artery in the neck: carotid-carotidal anastomosis: report of a case. Acta Neurol Latinoam 1955; 1: 71-78
• 7 Eastcott HH, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet 1954; 267 (6846) 994-996
• 8 DeBakey ME. Successful carotid endarterectomy for cerebrovascular insufficiency. Nineteen-year follow-up. JAMA 1975; 233 (10) 1083-1085
• 9 Cooley DA, Al-Naaman YD, Carton CA. Surgical treatment of arteriosclerotic occlusion of common carotid artery. J Neurosurg 1956; 13 (5) 500-506
• 10 Easton JD, Sherman DG. Stroke and mortality rate in carotid endarterectomy: 228 consecutive operations. Stroke 1977; 8 (5) 565-568
• 11 Easton JD, Saver JL, Albers GW , et al; American Heart Association; American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Interdisciplinary Council on Peripheral Vascular Disease. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke 2009; 40 (6) 2276-2293
• 12 Rohde LE, Lee RT. Pathophysiology of atherosclerotic plaque development and rupture: an overview. Semin Vasc Med 2003; 3 (4) 347-354
• 13 Poppert H, Sadikovic S, Sander K, Wolf O, Sander D. Embolic signals in unselected stroke patients: prevalence and diagnostic benefit. Stroke 2006; 37 (8) 2039-2043
• 14 Hart RG, Ng KH. Stroke prevention in asymptomatic carotid artery disease: revascularization of carotid stenosis is not the solution. Pol Arch Med Wewn 2015; 125 (5) 363-369
• 15 Saha SPWT, Whayne Jr TF, Mukherjee D. Evidence-based management of carotid artery disease. Int J Angiol 2010; 19 (1) e21-e24
• 16 Brott TG, Halperin JL, Abbara S , et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. J Am Coll Cardiol 2011; 57 (8) 1002-1044
• 17 O'Donnell MJ, Hankey GJ, Eikelboom JW. Antiplatelet therapy for secondary prevention of noncardioembolic ischemic stroke: a critical review. Stroke 2008; 39 (5) 1638-1646
• 18 Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 324 (7329) 71-86
• 19 Raman G, Moorthy D, Hadar N , et al. Management strategies for asymptomatic carotid stenosis: a systematic review and meta-analysis. Ann Intern Med 2013; 158 (9) 676-685
• 20 Saha SP, Rodgers-Fischl PM, Minion DJ, Ferraris VA, Davenport DL. Variability in carotid endarterectomy at a single medical center: an outcome and cost analysis. Int J Angiol 2012; 21 (4) 209-212
• 21 Kansara A, Miller D, Damani R, Fuerst D, Silver B, Chaturvedi S. Variability in carotid endarterectomy practice patterns within a metropolitan area. Stroke 2012; 43 (11) 3105-3107
• 22 Cao PG, de Rango P, Zannetti S, Giordano G, Ricci S, Celani MG. Eversion versus conventional carotid endarterectomy for preventing stroke. Cochrane Database Syst Rev 2001; (1) CD001921
• 23 Rerkasem K, Rothwell PM. Patch angioplasty versus primary closure for carotid endarterectomy. Cochrane Database Syst Rev 2009; (4) CD000160
• 24 Rerkasem K, Rothwell PM. Systematic review of randomized controlled trials of patch angioplasty versus primary closure and different types of patch materials during carotid endarterectomy. Asian J Surg 2011; 34 (1) 32-40
• 25 Malas M, Glebova NO, Hughes SE , et al. Effect of patching on reducing restenosis in the carotid revascularization endarterectomy versus stenting trial. Stroke 2015; 46 (3) 757-761
• 26 Ho KJ, Madenci AL, Semel ME , et al. Predictors and consequences of unplanned hospital readmission within 30 days of carotid endarterectomy. J Vasc Surg 2014; 60 (1) 77-84
• 27 Leichtle SW, Mouawad NJ, Welch K, Lampman R, Whitehouse Jr WM, Heidenreich M. Outcomes of carotid endarterectomy under general and regional anesthesia from the American College of Surgeons' National Surgical Quality Improvement Program. J Vasc Surg 2012; 56 (1) 81-8.e3
• 28 Lewis SC, Warlow CP, Bodenham AR , et al; GALA Trial Collaborative Group. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet 2008; 372 (9656) 2132-2142
• 29 Vaniyapong T, Chongruksut W, Rerkasem K. Local versus general anaesthesia for carotid endarterectomy. Cochrane Database Syst Rev 2013; 12: CD000126
• 30 Schechter MA, Shortell CK, Scarborough JE. Regional versus general anesthesia for carotid endarterectomy: the American College of Surgeons National Surgical Quality Improvement Program perspective. Surgery 2012; 152 (3) 309-314
• 31 Gomes M, Soares MO, Dumville JC , et al; GALA Collaborative Group. Cost-effectiveness analysis of general anaesthesia versus local anaesthesia for carotid surgery (GALA Trial). Br J Surg 2010; 97 (8) 1218-1225
• 32 Paraskevas KI, Mikhailidis DP, Oikonomou K, Verhoeven EL. Local versus general anesthesia for carotid endarterectomy: issues beyond stroke, myocardial infarction, and death rates. Angiology 2012; 63 (6) 405-408
• 33 de Weerd M, Greving JP, Hedblad B , et al. Prevalence of asymptomatic carotid artery stenosis in the general population: an individual participant data meta-analysis. Stroke 2010; 41 (6) 1294-1297
• 34 Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995; 273 (18) 1421-1428
• 35 Wu TY, Akopian G, Katz SG. Patients at elevated risk of major adverse events following endarterectomy for asymptomatic carotid stenosis. Am J Surg 2015; 209 (6) 1069-1073
• 36 Bennett KM, Scarborough JE, Shortell CK. Predictors of 30-day postoperative stroke or death after carotid endarterectomy using the 2012 carotid endarterectomy-targeted American College of Surgeons National Surgical Quality Improvement Program database. J Vasc Surg 2015; 61 (1) 103-111
• 37 Gupta PK, Ramanan B, Mactaggart JN , et al. Risk index for predicting perioperative stroke, myocardial infarction, or death risk in asymptomatic patients undergoing carotid endarterectomy. J Vasc Surg 2013; 57 (2) 318-326
• 38 Halliday A, Mansfield A, Marro J , et al; MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004; 363 (9420) 1491-1502
• 39 Rudarakanchana N, Dialynas M, Halliday A. Asymptomatic Carotid Surgery Trial-2 (ACST-2): rationale for a randomised clinical trial comparing carotid endarterectomy with carotid artery stenting in patients with asymptomatic carotid artery stenosis. Eur J Vasc Endovasc Surg 2009; 38 (2) 239-242
• 40 Markus HS, King A, Shipley M , et al. Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observational study. Lancet Neurol 2010; 9 (7) 663-671
• 41 Chambers BR, Donnan GA. Carotid endarterectomy for asymptomatic carotid stenosis. Cochrane Database Syst Rev 2005; (4) CD001923
• 42 Naylor AR. Why is the management of asymptomatic carotid disease so controversial?. Surgeon 2015; 13 (1) 34-43
• 43 MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists' Collaborative Group. Lancet 1991; 337 (8752) 1235-1243
• 44 North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325 (7) 445-453
• 45 Morgenstern LB, Fox AJ, Sharpe BL, Eliasziw M, Barnett HJ, Grotta JC ; North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group. The risks and benefits of carotid endarterectomy in patients with near occlusion of the carotid artery. Neurology 1997; 48 (4) 911-915
• 46 Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998; 351 (9113) 1379-1387
• 47 Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ. Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischemic attack and nondisabling stroke. Stroke 2004; 35 (12) 2855-2861
• 48 Charmoille E, Brizzi V, Lepidi S , et al. Thirty-day outcome of delayed versus early management of symptomatic carotid stenosis. Ann Vasc Surg 2015;
• 49 Rerkasem K, Rothwell PM. Systematic review of the operative risks of carotid endarterectomy for recently symptomatic stenosis in relation to the timing of surgery. Stroke 2009; 40 (10) e564-e572
• 50 Capoccia L, Sbarigia E, Speziale F, Toni D, Fiorani P. Urgent carotid endarterectomy to prevent recurrence and improve neurologic outcome in mild-to-moderate acute neurologic events. J Vasc Surg 2011; 53 (3) 622-627 , discussion 627–628
• 51 Rantner B, Schmidauer C, Knoflach M, Fraedrich G. Very urgent carotid endarterectomy does not increase the procedural risk. Eur J Vasc Endovasc Surg 2015; 49 (2) 129-136
• 52 Barbetta I, Carmo M, Mercandalli G , et al. Outcomes of urgent carotid endarterectomy for stable and unstable acute neurologic deficits. J Vasc Surg 2014; 59 (2) 440-446
• 53 Ferrero E, Ferri M, Viazzo A , et al. A retrospective study on early carotid endarterectomy within 48 hours after transient ischemic attack and stroke in evolution. Ann Vasc Surg 2014; 28 (1) 227-238
• 54 Alamowitch S, Eliasziw M, Barnett HJ ; North American Symptomatic Carotid Endarterectomy Trial (NASCET); ASA Trial Group; Carotid Endarterectomy (ACE) Trial Group. The risk and benefit of endarterectomy in women with symptomatic internal carotid artery disease. Stroke 2005; 36 (1) 27-31
• 55 Kuy S, Dua A, Desai SS , et al. Carotid endarterectomy national trends over a decade: does sex matter?. Ann Vasc Surg 2014; 28 (4) 887-892
• 56 Hedayati N, Humphries MD, Zhou W. Gender and outcomes of carotid artery interventions. Vasc Endovascular Surg 2014; 48 (2) 99-105
• 57 Guzman RP, Weighell W, Guzman C, Rodriguez-Leyva D. Female sex does not influence 30-day stroke and mortality rates after carotid endarterectomy. Ann Vasc Surg 2014; 28 (1) 245-252
• 58 Jim J, Dillavou ED, Upchurch Jr GR , et al; SVS Outcomes Committee. Gender-specific 30-day outcomes after carotid endarterectomy and carotid artery stenting in the Society for Vascular Surgery Vascular Registry. J Vasc Surg 2014; 59 (3) 742-748
• 59 Gasecki AP, Eliasziw M, Ferguson GG, Hachinski V, Barnett HJ ; North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group. Long-term prognosis and effect of endarterectomy in patients with symptomatic severe carotid stenosis and contralateral carotid stenosis or occlusion: results from NASCET. J Neurosurg 1995; 83 (5) 778-782
• 60 Ballotta E, Toniato A, Da Roit A, Lorenzetti R, Piatto G, Baracchini C. Carotid endarterectomy for asymptomatic carotid stenosis in the very elderly. J Vasc Surg 2015; 61 (2) 382-388
• 61 Reichmann BL, van Lammeren GW, Moll FL, de Borst GJ. Is age of 80 years a threshold for carotid revascularization?. Curr Cardiol Rev 2011; 7 (1) 15-21
• 62 Saha SPRA, Earle GF. Carotid endarterectomy in octagenarians and nonagenarians in a community hospital: An outcome analysis. Int J Angiol 2002; 11: 38-40 . Available at http://link.springer.com/article/10.1007%2Fs00547-001-0051-y
• 63 Wu TY, Anderson NE, Barber PA. Neurological complications of carotid revascularisation. J Neurol Neurosurg Psychiatry 2012; 83 (5) 543-550
• 64 Hill MD, Brooks W, Mackey A , et al; CREST Investigators. Stroke after carotid stenting and endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Circulation 2012; 126 (25) 3054-3061
• 65 Vellimana AK, Yarbrough CK, Blackburn S , et al. Intravenous tissue-type plasminogen activator therapy is an independent risk factor for symptomatic intracerebral hemorrhage after carotid endarterectomy. Neurosurgery 2014; 74 (3) 254-261
• 66 Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med 1995; 333 (24) 1581-1587
• 67 Orlický M, Vachata P, Bartoš R, Waldauf P, Sameš M. A selective carotid artery shunting for carotid endarterectomy: prospective MR DWI monitoring of embolization in a group of 754 patients. J Neurol Surg A Cent Eur Neurosurg 2015; 76 (2) 89-92
• 68 Galiñanes EL, Dombroviskiy VY, Hupp CS, Kruse RL, Vogel TR. Evaluation of readmission rates for carotid endarterectomy versus carotid artery stenting in the US Medicare population. Vasc Endovascular Surg 2014; 48 (3) 217-223
• 69 Rambachan A, Smith TR, Saha S, Eskandari MK, Bendok BR, Kim JY. Reasons for readmission after carotid endarterectomy. World Neurosurg 2014; 82 (6) e771-e776
• 70 Ho KJ, Madenci AL, McPhee JT , et al. Contemporary predictors of extended postoperative hospital length of stay after carotid endarterectomy. J Vasc Surg 2014; 59 (5) 1282-1290
• 71 Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 2001; 357 (9270) 1729-1737
• 72 Ringleb PA, Allenberg J, Brückmann H , et al; SPACE Collaborative Group. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 2006; 368 (9543) 1239-1247
• 73 Reiff T, Stingele R, Eckstein HH , et al; SPACE2-Study Group. Stent-protected angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy: SPACE2 - a three-arm randomised-controlled clinical trial. Int J Stroke 2009; 4 (4) 294-299
• 74 Yadav JS, Wholey MH, Kuntz RE , et al; Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy Investigators. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004; 351 (15) 1493-1501
• 75 Ederle J, Dobson J, Featherstone RL , et al; International Carotid Stenting Study investigators. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 2010; 375 (9719) 985-997 [Erratum in Lancet 2010;376(9735):90]
• 76 Bonati LH, Dobson J, Featherstone RL , et al; International Carotid Stenting Study investigators. Long-term outcomes after stenting versus endarterectomy for treatment of symptomatic carotid stenosis: the International Carotid Stenting Study (ICSS) randomised trial. Lancet 2015; 385 (9967) 529-538
• 77 Brott TG, Hobson II RW, Howard G , et al; CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010; 363 (1) 11-23
• 78 Usman AA, Tang GL, Eskandari MK. Metaanalysis of procedural stroke and death among octogenarians: carotid stenting versus carotid endarterectomy. J Am Coll Surg 2009; 208 (6) 1124-1131
• 79 Kuliha M, Roubec M, Procházka V , et al. Randomized clinical trial comparing neurological outcomes after carotid endarterectomy or stenting. Br J Surg 2015; 102 (3) 194-201
• 80 Choi JC, Johnston SC, Kim AS. Early outcomes after carotid artery stenting compared with endarterectomy for asymptomatic carotid stenosis. Stroke 2015; 46 (1) 120-125
• 81 McDonald RJ, McDonald JS, Therneau TM, Lanzino G, Kallmes DF, Cloft HJ. Comparative effectiveness of carotid revascularization therapies: evidence from a National Hospital Discharge Database. Stroke 2014; 45 (11) 3311-3319
• 82 Kolkert JL, Meerwaldt R, Geelkerken RH, Zeebregts CJ. Endarterectomy or carotid artery stenting: the quest continues part two. Am J Surg 2015; 209 (2) 403-412
• 83 Al-Damluji MS, Nagpal S, Stilp E, Remetz M, Mena C. Carotid revascularization: a systematic review of the evidence. J Interv Cardiol 2013; 26 (4) 399-410
• 84 Yoshida S, Bensley RP, Glaser JD , et al. The current national criteria for carotid artery stenting overestimate its efficacy in patients who are symptomatic and at high risk. J Vasc Surg 2013; 58 (1) 120-127
• 85 Morr S, Lin N, Siddiqui AH. Carotid artery stenting: current and emerging options. Med Devices (Auckl) 2014; 7: 343-355
• 86 Tu J, Wang S, Huo Z, Wu R, Yao C, Wang S. Repeated carotid endarterectomy versus carotid artery stenting for patients with carotid restenosis after carotid endarterectomy: Systematic review and meta-analysis. Surgery 2015; 157 (6) 1166-1173
• 87 Fokkema M, de Borst GJ, Nolan BW , et al; Vascular Study Group of New England. Carotid stenting versus endarterectomy in patients undergoing reintervention after prior carotid endarterectomy. J Vasc Surg 2014; 59 (1) 8-15.e1 , 2
• 88 Kastrup A, Schulz JB, Raygrotzki S, Gröschel K, Ernemann U. Comparison of angioplasty and stenting with cerebral protection versus endarterectomy for treatment of internal carotid artery stenosis in elderly patients. J Vasc Surg 2004; 40 (5) 945-951
• 89 Seretis K, Goudakos I, Vlachakis I, Anthimidis G, Papadimitriou D. Carotid artery disease in octogenarians: endarterectomy or stenting?. Int Angiol 2007; 26 (4) 353-360
• 90 Qureshi AI, Chaudhry SA, Qureshi MH, Suri MF. Rates and predictors of 5-year survival in a national cohort of asymptomatic elderly patients undergoing carotid revascularization. Neurosurgery 2015; 76 (1) 34-40 , discussion 40–41
• 91 Giri J, Parikh SA, Kennedy KF , et al. Proximal versus distal embolic protection for carotid artery stenting: a national cardiovascular data registry analysis. JACC Cardiovasc Interv 2015; 8 (4) 609-615
• 92 Gargiulo G, Stabile E, Sannino A, Perrino C, Trimarco B, Esposito G. Embolic protection devices during carotid artery stenting: Is there a difference between proximal occlusion and distal filter?. Int J Cardiol 2015; 187: 592-593
• 93 Khan AA, Chaudhry SA, Sivagnanam K, Hassan AE, Suri MF, Qureshi AI. Cost-effectiveness of carotid artery stent placement versus endarterectomy in patients with carotid artery stenosis. J Neurosurg 2012; 117 (1) 89-93
• 94 Vilain KR, Magnuson EA, Li H , et al; CREST Investigators. Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at standard surgical risk: results from the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke 2012; 43 (9) 2408-2416
• 95 Meschia JF, Bushnell C, Boden-Albala B , et al; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Functional Genomics and Translational Biology; Council on Hypertension. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45 (12) 3754-3832
• 96 Liapis CD, Bell PR, Mikhailidis D , et al; ESVS Guidelines Collaborators. ESVS guidelines. Invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg 2009; 37 (4, Suppl): 1-19
• 97 AbuRahma AF, Srivastava M, Hass SM , et al. Practice patterns of carotid endarterectomy as performed by different surgical specialties at a single institution and the effect on perioperative stroke and cost of preoperative imaging. J Vasc Surg 2014; 60 (5) 1232-1237
• 98 Naylor AR, Gaines PA, Rothwell PM. Who benefits most from intervention for asymptomatic carotid stenosis: patients or professionals?. Eur J Vasc Endovasc Surg 2009; 37 (6) 625-632
• 99 Dumont TM, Rughani AI. National trends in carotid artery revascularization surgery. J Neurosurg 2012; 116 (6) 1251-1257
• 100 McDonald JS, McDonald RJ, Fan J, Lanzino G, Kallmes DF, Cloft HJ. Effect of CREST Findings on Carotid Revascularization Practice in the United States. J Stroke Cerebrovasc Dis 2015; 24 (6) 1390-1396
• 101 Ali A, O'Callaghan A, Moloney T, Kelly C, Monoley D, Leahy A. The effect of carotid stenting on endarterectomy practice - A single institution experience. Surgeon 2014;