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.