Prognostic Factors of Long-term Survival to Guide Selection of Asymptomatic Patients for Carotid Endarterectomy

Abstract

Introduction According to the current guidelines, prophylactic carotid endarterectomy (CEA) should be considered for patients with asymptomatic carotid stenosis (ACS) who are at high-risk of becoming symptomatic, provided they have a 3- to 5-year life-expectancy and perioperative stroke/death rates are ≤3%. We reviewed the literature to identify negative prognostic factors for long-term survival in ACS patients to avoid offering CEA to those not likely to benefit from the procedure. Evidence acquisition PubMed/MedLine was searched until April 1, 2019, for risk prediction models to find ACS patients with poor long-term survival. Evidence synthesis Fourteen studies were identified. Cardiac disease/congestive heart failure, advanced age, chronic obstructive pulmonary disease, diabetes mellitus, dialysis/renal insufficiency, lack of statin use and active/previous smoking were negative predictors of long-term survival following CEA. The concomitant presence of >1 prognostic factor had a cumulative effect on long-term mortality rates. High-volume, experienced surgeons and type of hospital (academic rather than urban) were positive predictors and affected early and long-term survival rates. Conclusions The presence of one or more prognostic factors as well as the various risk prediction models can guide selection of ACS patient subgroups for which a prophylactic CEA should or should not be offered. Decisions to offer prophylactic CEA should weigh in factors like surgeon's experience and hospital expertise/volume. Asymptomatic patients not expected to live long enough to benefit from the procedure should not be considered for CEA, but should be offered best medical treatment.