In carotid endarterectomy (CEA) for symptomatic carotid stenosis, the NASCET trial defined 'symptomatic significant stenosis' requiring surgery. What degree of stenosis and symptom criterion defines the population with greatest absolute benefit from CEA?

• A 50-69% stenosis; benefit is moderate (absolute risk reduction ~7% at 5 years)
• B 70-99% stenosis with recent ipsilateral TIA or stroke; absolute risk reduction ~17% at 2 years ✓
• C 30-49% stenosis; CEA is beneficial regardless of symptoms
• D Any degree of stenosis in asymptomatic patients with >50% stenosis

Explanation

The NASCET trial showed that CEA for symptomatic stenosis 70-99% provides an absolute risk reduction of approximately 17% at 2 years (relative risk reduction ~65%) for ipsilateral stroke versus medical therapy alone. Surgery should be performed within 2 weeks of symptoms for maximum benefit. For 50-69% symptomatic stenosis, the absolute benefit is modest (~7% at 5 years). Surgery is not beneficial for stenosis <50% (symptomatic) or <60% (asymptomatic). ACAS trial established benefit for asymptomatic stenosis >60% with a much smaller absolute benefit (~5% at 5 years).

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.