Stroke: Should I Have Carotid Endarterectomy?
You may want to have a say in this decision, or you may simply want to follow your doctor's recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them.
Stroke: Should I Have Carotid Endarterectomy?
Get the facts
Your options
- Have carotid endarterectomy surgery.
- Don't have surgery. Keep taking medicines, or talk with your
doctor about other treatment.
Key points to remember
- Two
carotid arteries supply blood to the brain. When
plaque builds up in either artery, it can partly block
the blood flow to your brain and can cause a
stroke or
transient ischemic attack (TIA).
Carotid endarterectomy may help to prevent this.
- You are most likely to benefit from carotid surgery if you have
had symptoms of a TIA or stroke in the past 6 months and
plaque is blocking nearly three-quarters of one of your
carotid arteries. Your doctor may call this "70%
narrowing."1
- If less than half of
the artery is blocked by plaque, the risks of surgery are greater than the
benefits. Your doctor may call this "50% narrowing."1
- Your doctor may recommend surgery even if
your arteries are only moderately blocked (50% to 69% narrowing) if you have
had one of the following:
- One or more TIAs in the past 6 months.
- A series
of small strokes in the past 6 months, and each small stroke has left you a
little more disabled.
- A mild or moderate stroke in the past 6
months.
- If you and your doctor decide that you need
surgery, it is important to have it done by a skilled surgeon at a hospital
that has a good success rate in carotid endarterectomy.
- If you have less than 70% narrowing, taking medicines may work just as well as surgery to prevent a stroke or TIA, especially if you haven't already had one.2
- You may be able to try other treatment to reduce your risk of
TIA and stroke. This could include taking medicines and making healthy
lifestyle changes. Or you might be able to have
carotid artery stenting. Talk with your doctor to find
out if these treatments are right for you.
FAQs
Carotid
endarterectomy (say "kuh-RAW-tid en-dar-tuh-REK-tuh-mee") is surgery to remove
fatty buildup (plaque) from one of the
carotid arteries.
Carotid arteries supply
blood to the brain. When plaque builds up in either artery, it can partly block
the blood flow to your brain. This surgery may lower your risk of having a
transient ischemic attack (TIA) or
stroke.
During
carotid endarterectomy, your surgeon:
- Will make a cut in your neck just below the
jaw.
- Will open the carotid artery and carefully remove the plaque.
- May sew (graft) a vein from your leg onto the carotid artery to
widen or repair the artery.
- Will close the artery and skin incisions with stitches.
You may have tests to measure the amount of plaque in your
carotid arteries. These tests also help your doctor see how well blood flows
through the area that is narrowed by
plaque. Tests may include:
-
Carotid arteriogram.
- Carotid ultrasound.
- Computed tomography angiogram (CTA).
-
Magnetic resonance angiogram (MRA).
Most of the time, the amount of narrowing is described
as a percentage. For example, if plaque is blocking half of the artery, the
doctor may say the artery is 50% narrowed. If plaque is blocking nearly
three-quarters of the artery, the doctor may say the artery is 70%
narrowed.
Some of these tests can also check the blood vessels
above and below the neck. If those vessels are blocked or damaged, surgery may
not be helpful because the surgeon cannot easily operate on those areas.
No test can tell for sure which plaques are likely to cause a blood clot
to form and cause a TIA or stroke. But experts believe that irregular, jagged,
or unstable plaques are more likely than smooth plaques to cause problems.
A person who has a narrowed carotid artery that contains an
irregular or jagged plaque may be at greater risk for a stroke or TIA. These
tests can help your doctor see what kind of plaque is blocking the artery and
whether surgery is a good choice.
Carotid
endarterectomy reduces the risk of
TIA and
stroke in people who have already had a TIA or stroke and who have moderate to severe narrowing
(70% to 99%) of the carotid arteries.1
Risks of surgery depend on your age, your health, and the skill and
experience of the surgeon.
The major risks are:
-
Stroke,
heart attack, and death. Most deaths that occur during
this surgery are caused by a heart attack.
- Breathing problems.
-
High blood pressure.
- Infection.
- Nerve
injury.
- Bleeding in the brain.
You and your doctor will decide whether the risks of
surgery are higher or lower than your risk of stroke.
This
surgery is not advised for people who have:
-
TIAs that are
caused by narrowed blood vessels in the back of the brain.
- Severe
disease of the arteries that bring blood to the heart.
- Uncontrolled high blood pressure.
- Severe disease of
the arteries that branch off from the carotid arteries.
- Other
serious medical problems, such as kidney failure or
heart failure. These can make surgery more
risky.
You may be able to
try other treatment to reduce your risk of TIA and stroke. These include taking
medicines and making healthy lifestyle changes. Or you might be able to have
carotid artery stenting.
Medicines
In some people, taking medicines to
reduce the risk of blood clots, making lifestyle changes, and taking medicines
to control
high blood pressure and
cholesterol are enough to reduce the risk of
transient ischemic attack (TIA) and
stroke. If you have less than 70% narrowing of your carotid arteries, especially if you haven't already had a stroke or TIA, medicine may work just as well as surgery to prevent a stroke.2 Talk with your doctor about whether this
treatment is an option for you.
Stenting
Carotid artery stenting is similar to
coronary
angioplasty, which is done to open blocked arteries in
the heart. It may be done instead of surgery to prevent TIA or stroke.
In this procedure, a tube is threaded through an artery in the groin and
passed up to the carotid arteries. A tiny balloon is used to enlarge the
narrowed portion of the artery. A small, expandable tube called a stent is used to keep the artery open.
Carotid artery stenting may work as well as surgery to prevent stroke and other problems in some people who have narrowed carotid
arteries.3, 4 Talk with your doctor about whether stenting is an option for
you.
Carotid artery stenting is not a good choice for people older than age 70. Studies have shown that for people in this age group, the risk of stroke or death during the procedure is too high. Carotid endarterectomy is safer for people older than 70.
Your doctor may suggest that you have this surgery if:
- You have had a mild stroke or one or more TIAs in the past 6
months and you have 70% or more narrowing in your
carotid artery.
- You have a low risk of complications from the
surgery.
- You have 50% to 69% narrowing and have had at least one of
the following:
- One or more TIAs in the past 6 months.
- A series of small strokes in the past 6 months, and each small
stroke has left you a little more disabled.
- A mild or moderate
stroke in the past 6 months.
Compare your options
|
|
|
|
|
What is usually involved?
|
|
|
|
What are the benefits?
|
|
|
|
What are the risks and side effects?
|
|
|
Have carotid
endarterectomy
Have carotid
endarterectomy
- You are asleep
during the surgery.
- You stay in the hospital for 1 to 3 days.
- You can go back to your daily activities within a week, if they
are not too strenuous.
- Your neck may ache for up to 2 weeks after
carotid endarterectomy.
- Surgery reduces the
risk of
transient ischemic attack (TIA) and stroke in people
who have already had a TIA or stroke and who have moderate to severe narrowing (70% to 99%) of the carotid arteries.1
- Surgery can be done at any time. But if you
have had a TIA or mild stroke, you will benefit most if surgery is done within 2 weeks.
- The
benefits of surgery may not last if you don't take medicines or make healthy
lifestyle changes.
- All surgery has risks, including bleeding,
infection, and nerve damage.
- Other risks include:
- Stroke, heart attack, and
death.
- Heart and breathing problems.
- High blood
pressure.
Don't have
endarterectomy
Don't have
endarterectomy
- You can keep taking
medicines or try medicines along with lifestyle changes to reduce your risk of
stroke.
- If you decide that surgery is too risky for you, you can talk
with your doctor about other treatment, such as
carotid artery stenting.
- You avoid the risks of
surgery.
- Other treatment such as medical therapy or stenting may reduce
your risk of TIA and stroke.
- You may
still have a TIA or stroke.
- You still need to make healthy
lifestyle changes to reduce your risk.
- If you have had symptoms of
a stroke or TIA and you have moderate to severe narrowing (70% to 99%) of the carotid arteries, medicines alone may not work as well as surgery to prevent
stroke.2
Personal stories
Are you interested in what others decided to do? Many people have faced this decision. These personal stories may help you decide.
I had a mild
stroke about 3 months ago. Fortunately, it wasn't too bad. With a lot of
therapy, I am now able to walk and do many of the things I did before, although
my right side is weak. I have a fair amount of narrowing in my carotid
arteries, so I am going to have the surgery. I would hate to have another
stroke and lose any more function.
I had a
mini-stroke (my doctor called it a TIA) about 2 months ago. I had the test that
looks at the carotid arteries when the major hospital sent a mobile unit to our
area. I have about 65% narrowing in the artery. I could have the carotid
surgery, but the closest major hospital is a couple hundred miles away, and I
would rather not have surgery so far from home.
I am
fortunate to live in a major city that has very good hospitals. My doctor knows
his complication rate from carotid surgery, and it is very low. Other than my
narrow arteries, I am in good health and I've never had a stroke or even a
mini-stroke. I think I stand to gain enough from having surgery to make up for
the risks involved in it.
I have never had any symptoms of a stroke
or a TIA, although my carotid arteries are about 70% narrowed. The risks of the
surgery sound like they are almost as high as the benefit I would gain. Since I
don't have any symptoms, I would rather not have surgery for now. Until
something happens, I'll take my medicines every day, eat right, and exercise.
What matters most to you?
Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.
Reasons to have carotid endarterectomy
Reasons not to have endarterectomy
I feel that the benefits of surgery are greater than the risks.
I feel that the risks of surgery are too high for me.
More important
Equally important
More important
I am confident that my surgeon has the skill and experience to perform a successful surgery.
I'm not sure about my surgeon's skill and experience with this surgery.
More important
Equally important
More important
I want to have surgery if it will lower my risk for stroke.
I don't want to have surgery for any reason.
More important
Equally important
More important
I don't want to try other treatments that might not work.
I want to talk with my doctor about other treatments.
More important
Equally important
More important
My other important reasons:
My other important reasons:
More important
Equally important
More important
Where are you leaning now?
Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.
Having endarterectomy
NOT having endarterectomy
Leaning toward
Undecided
Leaning toward
What else do you need to make your decision?
1.
Are the benefits of surgery highest in people with no symptoms and only a small blockage in their carotid arteries?
2.
If you decide that surgery is right for you, does it matter who performs it or where it is done?
3.
If you decide that surgery is not for you, are there other treatments you can try?
1.
How sure do you feel right now about your decision?
Not sure at all
Somewhat sure
Very sure
2.
Check what you need to do before you make this decision.
3.
Use the following space to list questions, concerns, and next steps.
Your Summary
Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision.
Key concepts that you understood
Key concepts that may need review
Credits
| Credits |
Healthwise Staff |
| Primary Medical Reviewer |
E. Gregory Thompson, MD - Internal Medicine |
| Specialist Medical Reviewer |
Karin M. Lindholm, DO - Neurology |
References
Citations
-
Rerkasem K, Rothwell PM (2011). Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database of Systematic Reviews (4).
-
Furie KL, et al (2011). Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(1): 227–276. Also available online: http://stroke.ahajournals.org/content/42/1/227.full.
-
Brott TG, et al. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. The New England Journal of Medicine, 363(1): 11–23.
-
International Carotid Stenting Study Investigators (2010). 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, 375(9719): 985–997.
You may want to have a say in this decision, or you may simply want to follow your doctor's recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them.
Stroke: Should I Have Carotid Endarterectomy?
Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision.
- Get the facts
- Compare your options
- What matters most to you?
- Where are you leaning now?
- What else do you need to make your decision?
1. Get the facts
Your options
- Have carotid endarterectomy surgery.
- Don't have surgery. Keep taking medicines, or talk with your
doctor about other treatment.
Key points to remember
- Two
carotid arteries supply blood to the brain. When
plaque builds up in either artery, it can partly block
the blood flow to your brain and can cause a
stroke or
transient ischemic attack (TIA).
Carotid endarterectomy may help to prevent this.
- You are most likely to benefit from carotid surgery if you have
had symptoms of a TIA or stroke in the past 6 months and
plaque is blocking nearly three-quarters of one of your
carotid arteries. Your doctor may call this "70%
narrowing."1
- If less than half of
the artery is blocked by plaque, the risks of surgery are greater than the
benefits. Your doctor may call this "50% narrowing."1
- Your doctor may recommend surgery even if
your arteries are only moderately blocked (50% to 69% narrowing) if you have
had one of the following:
- One or more TIAs in the past 6 months.
- A series
of small strokes in the past 6 months, and each small stroke has left you a
little more disabled.
- A mild or moderate stroke in the past 6
months.
- If you and your doctor decide that you need
surgery, it is important to have it done by a skilled surgeon at a hospital
that has a good success rate in carotid endarterectomy.
- If you have less than 70% narrowing, taking medicines may work just as well as surgery to prevent a stroke or TIA, especially if you haven't already had one.2
- You may be able to try other treatment to reduce your risk of
TIA and stroke. This could include taking medicines and making healthy
lifestyle changes. Or you might be able to have
carotid artery stenting. Talk with your doctor to find
out if these treatments are right for you.
FAQs
What is carotid endarterectomy?
Carotid
endarterectomy (say "kuh-RAW-tid en-dar-tuh-REK-tuh-mee") is surgery to remove
fatty buildup (plaque) from one of the
carotid arteries.
Carotid arteries supply
blood to the brain. When plaque builds up in either artery, it can partly block
the blood flow to your brain. This surgery may lower your risk of having a
transient ischemic attack (TIA) or
stroke.
During
carotid endarterectomy , your surgeon:
- Will make a cut in your neck just below the
jaw.
- Will open the carotid artery and carefully remove the plaque.
- May sew (graft) a vein from your leg onto the carotid artery to
widen or repair the artery.
- Will close the artery and skin incisions with stitches.
What kinds of tests can help you decide if surgery is right for you?
You may have tests to measure the amount of plaque in your
carotid arteries. These tests also help your doctor see how well blood flows
through the area that is narrowed by
plaque. Tests may include:
-
Carotid arteriogram.
- Carotid ultrasound.
- Computed tomography angiogram (CTA).
-
Magnetic resonance angiogram (MRA).
Most of the time, the amount of narrowing is described
as a percentage. For example, if plaque is blocking half of the artery, the
doctor may say the artery is 50% narrowed. If plaque is blocking nearly
three-quarters of the artery, the doctor may say the artery is 70%
narrowed.
Some of these tests can also check the blood vessels
above and below the neck. If those vessels are blocked or damaged, surgery may
not be helpful because the surgeon cannot easily operate on those areas.
No test can tell for sure which plaques are likely to cause a blood clot
to form and cause a TIA or stroke. But experts believe that irregular, jagged,
or unstable plaques are more likely than smooth plaques to cause problems.
A person who has a narrowed carotid artery that contains an
irregular or jagged plaque may be at greater risk for a stroke or TIA. These
tests can help your doctor see what kind of plaque is blocking the artery and
whether surgery is a good choice.
How well does this surgery work?
Carotid
endarterectomy reduces the risk of
TIA and
stroke in people who have already had a TIA or stroke and who have moderate to severe narrowing
(70% to 99%) of the carotid arteries.1
What are the risks of carotid endarterectomy?
Risks of surgery depend on your age, your health, and the skill and
experience of the surgeon.
The major risks are:
-
Stroke,
heart attack, and death. Most deaths that occur during
this surgery are caused by a heart attack.
- Breathing problems.
-
High blood pressure.
- Infection.
- Nerve
injury.
- Bleeding in the brain.
You and your doctor will decide whether the risks of
surgery are higher or lower than your risk of stroke.
Who should not have carotid endarterectomy?
This
surgery is not advised for people who have:
-
TIAs that are
caused by narrowed blood vessels in the back of the brain.
- Severe
disease of the arteries that bring blood to the heart.
- Uncontrolled high blood pressure.
- Severe disease of
the arteries that branch off from the carotid arteries.
- Other
serious medical problems, such as kidney failure or
heart failure. These can make surgery more
risky.
Are other treatments available?
You may be able to
try other treatment to reduce your risk of TIA and stroke. These include taking
medicines and making healthy lifestyle changes. Or you might be able to have
carotid artery stenting.
Medicines
In some people, taking medicines to
reduce the risk of blood clots, making lifestyle changes, and taking medicines
to control
high blood pressure and
cholesterol are enough to reduce the risk of
transient ischemic attack (TIA) and
stroke. If you have less than 70% narrowing of your carotid arteries, especially if you haven't already had a stroke or TIA, medicine may work just as well as surgery to prevent a stroke.2 Talk with your doctor about whether this
treatment is an option for you.
Stenting
Carotid artery stenting is similar to
coronary
angioplasty, which is done to open blocked arteries in
the heart. It may be done instead of surgery to prevent TIA or stroke.
In this procedure, a tube is threaded through an artery in the groin and
passed up to the carotid arteries. A tiny balloon is used to enlarge the
narrowed portion of the artery. A small, expandable tube called a stent is used to keep the artery open.
Carotid artery stenting may work as well as surgery to prevent stroke and other problems in some people who have narrowed carotid
arteries.3, 4 Talk with your doctor about whether stenting is an option for
you.
Carotid artery stenting is not a good choice for people older than age 70. Studies have shown that for people in this age group, the risk of stroke or death during the procedure is too high. Carotid endarterectomy is safer for people older than 70.
Why might your doctor recommend carotid endarterectomy?
Your doctor may suggest that you have this surgery if:
- You have had a mild stroke or one or more TIAs in the past 6
months and you have 70% or more narrowing in your
carotid artery.
- You have a low risk of complications from the
surgery.
- You have 50% to 69% narrowing and have had at least one of
the following:
- One or more TIAs in the past 6 months.
- A series of small strokes in the past 6 months, and each small
stroke has left you a little more disabled.
- A mild or moderate
stroke in the past 6 months.
2. Compare your options
| |
Have carotid
endarterectomy
|
Don't have
endarterectomy
|
| What is usually involved? |
- You are asleep
during the surgery.
- You stay in the hospital for 1 to 3 days.
- You can go back to your daily activities within a week, if they
are not too strenuous.
- Your neck may ache for up to 2 weeks after
carotid endarterectomy.
|
- You can keep taking
medicines or try medicines along with lifestyle changes to reduce your risk of
stroke.
- If you decide that surgery is too risky for you, you can talk
with your doctor about other treatment, such as
carotid artery stenting.
|
| What are the benefits? |
- Surgery reduces the
risk of
transient ischemic attack (TIA) and stroke in people
who have already had a TIA or stroke and who have moderate to severe narrowing (70% to 99%) of the carotid arteries.1
- Surgery can be done at any time. But if you
have had a TIA or mild stroke, you will benefit most if surgery is done within 2 weeks.
|
- You avoid the risks of
surgery.
- Other treatment such as medical therapy or stenting may reduce
your risk of TIA and stroke.
|
| What are the risks and side effects? |
- The
benefits of surgery may not last if you don't take medicines or make healthy
lifestyle changes.
- All surgery has risks, including bleeding,
infection, and nerve damage.
- Other risks include:
- Stroke, heart attack, and
death.
- Heart and breathing problems.
- High blood
pressure.
|
- You may
still have a TIA or stroke.
- You still need to make healthy
lifestyle changes to reduce your risk.
- If you have had symptoms of
a stroke or TIA and you have moderate to severe narrowing (70% to 99%) of the carotid arteries, medicines alone may not work as well as surgery to prevent
stroke.2
|
Personal stories
Are you interested in what others decided to do? Many people have faced this decision. These
personal stories
may help you decide.
Personal stories about carotid endarterectomy surgery
These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.
"I had a mild stroke about 3 months ago. Fortunately, it wasn't too bad. With a lot of therapy, I am now able to walk and do many of the things I did before, although my right side is weak. I have a fair amount of narrowing in my carotid arteries, so I am going to have the surgery. I would hate to have another stroke and lose any more function."
"I had a mini-stroke (my doctor called it a TIA) about 2 months ago. I had the test that looks at the carotid arteries when the major hospital sent a mobile unit to our area. I have about 65% narrowing in the artery. I could have the carotid surgery, but the closest major hospital is a couple hundred miles away, and I would rather not have surgery so far from home."
"I am fortunate to live in a major city that has very good hospitals. My doctor knows his complication rate from carotid surgery, and it is very low. Other than my narrow arteries, I am in good health and I've never had a stroke or even a mini-stroke. I think I stand to gain enough from having surgery to make up for the risks involved in it."
"I have never had any symptoms of a stroke or a TIA, although my carotid arteries are about 70% narrowed. The risks of the surgery sound like they are almost as high as the benefit I would gain. Since I don't have any symptoms, I would rather not have surgery for now. Until something happens, I'll take my medicines every day, eat right, and exercise."
3. What matters most to you?
Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.
Reasons to have carotid endarterectomy
Reasons not to have endarterectomy
I feel that the benefits of surgery are greater than the risks.
I feel that the risks of surgery are too high for me.
More important
Equally important
More important
I am confident that my surgeon has the skill and experience to perform a successful surgery.
I'm not sure about my surgeon's skill and experience with this surgery.
More important
Equally important
More important
I want to have surgery if it will lower my risk for stroke.
I don't want to have surgery for any reason.
More important
Equally important
More important
I don't want to try other treatments that might not work.
I want to talk with my doctor about other treatments.
More important
Equally important
More important
My other important reasons:
My other important reasons:
More important
Equally important
More important
4. Where are you leaning now?
Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.
Having endarterectomy
NOT having endarterectomy
Leaning toward
Undecided
Leaning toward
5. What else do you need to make your decision?
Check the facts
1.
Are the benefits of surgery highest in people with no symptoms and only a small blockage in their carotid arteries?
You're right. You are most likely to benefit from surgery if you have had symptoms in the past 6 months and you have plaque that is blocking nearly three-quarters of your carotid artery.
2.
If you decide that surgery is right for you, does it matter who performs it or where it is done?
You're right. It's important to find a skilled surgeon at a hospital that has a good success rate with this surgery.
3.
If you decide that surgery is not for you, are there other treatments you can try?
You're right. You may be able to try other treatment, such as taking medicines and making healthy lifestyle changes or having carotid artery stenting. Talk with your doctor.
Decide what's next
1.
Do you understand the options available to you?
2.
Are you clear about which benefits and side effects matter most to you?
3.
Do you have enough support and advice from others to make a choice?
Certainty
1.
How sure do you feel right now about your decision?
Not sure at all
Somewhat sure
Very sure
2.
Check what you need to do before you make this decision.
3.
Use the following space to list questions, concerns, and next steps.
Credits
| By |
Healthwise Staff |
| Primary Medical Reviewer |
E. Gregory Thompson, MD - Internal Medicine |
| Specialist Medical Reviewer |
Karin M. Lindholm, DO - Neurology |
References
Citations
-
Rerkasem K, Rothwell PM (2011). Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database of Systematic Reviews (4).
-
Furie KL, et al (2011). Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(1): 227–276. Also available online: http://stroke.ahajournals.org/content/42/1/227.full.
-
Brott TG, et al. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. The New England Journal of Medicine, 363(1): 11–23.
-
International Carotid Stenting Study Investigators (2010). 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, 375(9719): 985–997.
Note: The "printer friendly" document will not contain all the information available in the online document some Information (e.g. cross-references to other topics, definitions or medical illustrations) is only available in the online version.
Last Revised:
January 3, 2013
Rerkasem K, Rothwell PM (2011). Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database of Systematic Reviews (4).
Furie KL, et al (2011). Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42(1): 227–276. Also available online: http://stroke.ahajournals.org/content/42/1/227.full.
Brott TG, et al. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. The New England Journal of Medicine, 363(1): 11–23.
International Carotid Stenting Study Investigators (2010). 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, 375(9719): 985–997.