In carotid endarterectomy (CEA) for symptomatic carotid stenosis, the NASCET trial established the benefit in stenosis >70%. Which statement regarding the operative timing is most consistent with current guidelines?

• A CEA should be delayed 4–6 weeks after TIA to allow plaque stabilisation
• B CEA is most beneficial when performed 3 months after the index event
• C CEA provides no benefit over medical therapy if performed within 48 hours of TIA
• D CEA should be performed within 14 days of a TIA or minor stroke for maximum stroke prevention benefit ✓

Explanation

Multiple randomised and registry studies demonstrate that the stroke prevention benefit of CEA is time-sensitive: the risk of recurrent stroke is highest in the first 2 weeks after a TIA or minor stroke (crescendo TIA risk >10% in the first 48 hours). Current NICE, ESO, and SVS guidelines recommend CEA within 14 days (ideally within 48–72 hours if stable) of the index event. Delaying surgery eliminates much of the preventive benefit. The earlier historical practice of waiting 4–6 weeks was based on fear of reperfusion haemorrhage, but evidence supports early intervention in neurologically stable patients.

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

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Written and medically reviewed by the StethoPrep medical team.