Cerebrovascular and Neurovascular Disease of the Neck
Grading stenosis
NASCET compares the narrowest residual lumen with the normal distal internal carotid artery; ECST uses an estimated normal bulb, so an ECST 80% is roughly a NASCET 70%. Quote the method used by the trial you are citing. Near-occlusion with a string sign behaves differently - low pressure gradient but high stroke risk - and is a common trap.
Who benefits
For symptomatic disease (amaurosis fugax, TIA, or minor stroke within six months), carotid endarterectomy is indicated at 70–99%, individualized at 50–69%, and medical therapy alone below 50%. Operate within two weeks of the index event, ideally days 3–7; benefit approaches zero by six months. Asymptomatic stenosis of 60% or more is increasingly managed with intensive medical therapy, reserving intervention for higher-risk plaque features or low-risk patients. Carotid stenting suits hostile necks (radiation, prior surgery, high bifurcation, restenosis), but CREST showed higher periprocedural stroke risk in patients over 70.
Perioperative care and complications
Continue aspirin and statin; prophylactic dual antiplatelet therapy is not routine for endarterectomy. Expanding hematoma with airway compromise is the most urgent complication - open the wound at the bedside. Hypoglossal injury deviates the tongue toward the side of injury; vagal or recurrent laryngeal injury causes hoarseness; marginal mandibular injury causes asymmetric smile; glossopharyngeal injury causes dysphagia. Hyperperfusion syndrome presents days later with headache, seizure, or hemorrhage in high-grade stenosis with poor blood pressure control.
Rule of thumb: a symptomatic 80% stenosis repaired on day five beats the same operation at week twelve - timing is part of the indication.