How Safe Is Endarterectomy for Carotid Near-Occlusion?

TOPLINENearly one third of patients scheduled for carotid endarterectomy (CEA) had carotid near-occlusion (NO), mostly in subtle forms. Carotid NO was not associated with a higher risk for preoperative recurrent ischaemic events or stroke or death within 30 days of the procedure compared with conventional carotid stenosis (CS), but hyperperfusion syndrome occurred more than twice as often after CEA.METHODOLOGYResearchers conducted a prospective cohort study to determine the prevalence of carotid NO in patients with CS scheduled for CEA and to assess whether it was associated with preoperative recurrent ischaemic cerebrovascular events, procedural stroke, death, and postoperative hyperperfusion syndrome.They included 443 patients (mean age, 70 years; 68% men) treated at a single tertiary stroke centre between 2012 and 2015; of these, 20% were asymptomatic, and 14% had suspected symptoms. Symptomatic patients underwent CEA at a median of 12 days after presenting with symptoms that prompted medical attention.Preoperative CT angiographies (CTAs) were reviewed by neuroradiologists and a radiology resident. Conventional stenosis was defined as CS of at least 50% according to the North American Symptomatic Carotid Endarterectomy Trial criteria. Subtle NO was defined as a side‑to‑side difference of at least 1 mm in the distal internal carotid artery (ICA) diameter, and NO with full collapse was defined as an ipsilateral distal ICA diameter of 2 mm or less and/or an ipsilateral to contralateral ICA diameter ratio of 0.42 or less.The researchers compared the risks for preoperative recurrent ischaemic cerebrovascular events after the decision to operate, 30-day procedural stroke, death, and hyperperfusion syndrome across stenosis subtypes.TAKEAWAYOn preoperative CTA, ipsilateral NO was detected in 32% of patients; of these, 87% had subtle NO and 13% had full collapse NO.Recurrent ischaemic cerebrovascular events were more frequent in patients with carotid NO than in those with conventional stenosis (13.0% vs 7.6%), but the difference did not reach statistical significance.No significant difference was observed in stroke or death within 30 days of CEA between patients with carotid NO and those with conventional stenosis.Hyperperfusion syndrome after CEA occurred more often in patients with NO than in those with conventional stenosis (7.0% vs 2.7%; age-adjusted odds ratio, 2.8; 95% CI, 1.1-7.1). One patient with subtle NO subsequently died from an intracranial haemorrhage attributed to hyperperfusion syndrome. Other procedural complication rates were similar between the subtle and full collapse NO groups.IN PRACTICE"[The study] findings highlight important considerations for managing NO patients undergoing CEA. Their higher risk of hyperperfusion syndrome increases the likelihood of procedural complications, making strict perioperative blood pressure control essential to prevent ICH [intracranial haemorrhage] and related events," the authors wrote.SOURCEThis study was led by Henrietta Törmänen, Helsinki University Hospital, Helsinki, Finland. It was published online on October 16, 2026, in the Journal of Neurology.LIMITATIONSThe NO was defined on the basis of normal variation in the ICA, which may not be fully accurate. The study included patients who underwent CEA, and none received best medical therapy alone, introducing potential selection bias. Because the full collapse NO subgroup was small, the study may have been underpowered to detect differences in the risk between groups.DISCLOSURESThis study was supported by the Hospital District of Helsinki and Uusimaa Research Grants, Perkléns Stiftelse, Sigrid Jusélius Foundation, and Jane and Aatos Erkko Foundation. The authors did not declare any conflicts of interest.This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.