Early and Long‐Term Outcomes of Carotid Endarterectomy in Patients With Carotid Near‐Occlusion Versus Preocclusive Carotid Stenosis
Sara Speziali, Cecilia Farnetani, Roberto Falso, Brigida Biancofiore, Rossella Di Domenico, Marco Campolmi, Elena Giacomelli, Walter Dorigo, Raffaele PulliABSTRACT
Background
The clinical role of carotid endarterectomy (CEA) in patients with carotid near‐occlusion (CNO) remains a subject of ongoing debate, and comparative data regarding its long‐term efficacy versus preocclusive carotid stenosis is limited. This study aimed to evaluate and compare the perioperative and long‐term outcomes of CEA in these two distinct subsets of high‐grade carotid disease.
Methods
A retrospective analysis was conducted on a prospectively maintained database of 1775 consecutive CEAs performed at a single center between January 2014 and September 2025. The study cohort included 81 procedures for CNO (Group 1) and 144 for preocclusive carotid stenosis > 95% with distal lumen recovery (Group 2). CNO was defined by distal internal carotid artery caliber reduction and further stratified by the presence of full distal collapse.
Results
Results showed that patients in Group 2 were significantly older than those in Group 1 (76 ± 8 vs. 72 ± 8 years; p < 0.001). Symptomatic presentation was more frequent in Group 1 (35.8% vs. 24.3%; p = 0.06), and concordant ipsilateral ischemic brain lesions were significantly more common in CNO patients (24.5% vs. 9%; p = 0.001). Regarding perioperative safety, no 30‐day deaths or major neurologic events occurred in Group 1, while Group 2 had a 30‐day stroke/death rate of 3.4% ( p = 0.08 vs. Group 1). During a median follow‐up of 30 months (range 1–140), the estimated 6‐year overall survival was 84% for Group 1% and 73% for Group 2 ( p = 0.1). Notably, ipsilateral stroke at 6 years occurred in 0% of CNO patients compared with 8.5% in the preocclusive group ( p = 0.03). Stroke‐free survival at 6 years was 84% in Group 1% and 71% in Group 2 ( p = 0.09). While freedom from restenosis was comparable (78.5% vs. 86.3%; p = 0.2), late carotid occlusion was significantly more frequent in the CNO group (6% vs. 0%; p = 0.02).
Conclusions
In this single‐center series, patients undergoing CEA for carotid near‐occlusion demonstrated favorable perioperative safety and a lower observed incidence of long‐term ipsilateral stroke during follow‐up compared with those treated for preocclusive stenosis, even in the presence of full distal collapse. The absence of a medically managed control group and the small number of events made these findings hypothesis‐generating. However, the higher incidence of late restenosis and occlusion in near‐occlusion highlights the importance of a personalized, intensified postoperative surveillance, particularly for patients with full distal collapse.