Carotid Endarterectomy for Stroke Prevention:

Indonesian Experience
Prof. Dr.med. Rasjid Soeparwata, SpB, SpBTKV(K), SpB(K)V
Cardiothoracic and Vascular Surgeon, Division of Vascular and Endovascular Surgery,
Faculty of Medicine Universitas Indonesia/Cipto Mangunkusumo General Hospital
The 39th Biennial World Congress of The International College of Surgeons
October 20th 24th 2014, Bali, Indonesia

Abstract
Stroke is the third global leading cause of death after cancer and cardiac disease and also the number
one cause of long life disability with narrow therapeutic windows for pharmacological reperfusion
therapy. Futhermore, stroke now is first leading cause of death in Indonesia. According to recent
studies, one in every 6 person is going to have stroke in their lifetime. In addition, carotid stenosis
interferes blood flow to brainstem leading to autonomic dysfunction, which causes heart rate
variability, carotid baroreceptor, and chemoreceptor function, which also could predict the
cardiovascular and cerebrovascular morbidity and mortality. The improvement of treating acute phase
is accompanied by the fact that successful recanalization and subsequent reperfusion is not necessarily
followed by brain tissue reperfusion. Recently, several mechanical recanalization methods were
introduced in addition to thrombolytic therapy. Nevertheless, the evidence supporting these methods
is still limited and further studies are needed to establish the role of such methods in treatment of
stroke. Given the aforementioned facts, it seems preventive measure will be more favorable to provide
better outcomes. One of the commonest underlying diseases of ischemic stroke is carotid stenosis.
Therefore, it is important to correct the stenosis to prevent stroke. There are currently two approaches
in correcting stenosis in carotid artery: carotid endarterectomy and carotid artery stenting.
Carotid endarterectomy (CEA) is a surgical technique of removing plaque, which has been used for
60 years ago and was performed for the first time by Michael E. DeBakey in 1953. Large randomized
controlled trials have documented that CEA is a highly effective in preventing stroke among patients
with carotid stenosis and recent transient ischemic attack or cerebral infarction. A clear separation
between symptomatic and asymptomatic carotid artery stenosis is critical, because in CEA is proven
highly benefit with symptomatic patients but only specific/ marginal benefit in asymptomatic patients.
Prompt evaluation and triage of patients with symptomatic carotid artery stenosis are essential to
minimize the risk of early recurrent cerebrovascular events. Prospective studies have shown that the
risk of ipsilateral stroke is high within the first 90 days, and especially within the first month, after
TIA. Urgent initiation of treatment can reduce the risk by up to 80%. Recently, a scoring system was
propose, prospectively, validated, and widely adopted to estimated the short-term risk of ipsilateral
stroke after TIA, which acronym as ABCD (age, blood pressure, clinical features, duration of TIA,
and diabetes mellitus). Patients with symptomatic severe carotid artery stenosis should go invasive
treatment unless the risk of intervention is considered to be prohibitively high.
In early 2000s, there are two randomised controlled trials of CEA versus best treatment alone in
patient with recently symptomatic carotid stenosis, which are The European Carotid Surgery Trial
(ECST) and The North American Symptomatic Carotid Endarterectomy Trial (NASCET). Both
studies shows clear decreases the overall risk of stroke in patient with recently symptomatic severe

(70-99%) carotid stenosis. After that, the VA Clinical Studies Program 309 found that CEA also
benefit for patients with moderate (>50%) stenosis. Currently, CEA also proven appropriate for some
asymptomatic patients. A very large study (n = 1.719) published in 2012, named ACAS study which
try to develop risk prediction model or scoring system for determining appropriateness of CEA in
ACAS patient based on the 5-year survival after CEA.
One of the common question is when to do surgery. Based on pooled analysis of the RCTs, treatment
should be performed on urgent basis after a TIA, especially 2 weeks after that. When patients treated
with CEA within 2 weeks, between 2 and 4 weeks, and after 4 weeks; the absolute risk reduction
decreased from 23% to 16% and then to 8% respectively.
In the era of evidence jungle the interdisciplinary approach seems to become an inevitable option in
treating stroke to provide the best possible therapy for patients. The adaptation of interdisciplinary
acute stroke center concept was pioneered in Indonesia by Faculty of Medicine Universitas Indonesia
and Cipto Mangunkusumo General Hospital in form of establishment of a Carotid Team; which
comprises of experts from neurology, vascular surgery, neurosurgery, cardiology, radiology, and
clinical pathology field. Furthermore improving public stroke-information may influence the main
sociocultural and economical factors and the access to medical and surgical care for many stroke
victims. With well-organized stroke-emergency transport services, well-educated neurological and
vascular expertise especially for performing medical and surgical will make treatment like Carotid
Endarterectomy (CEA) possible and available for patients.
After establishment of interdisciplinary team (the Head of which Prof. Dr. Teguh Ranakusuma, SpS)
i.e. from 2009-2014 in RSCM Kencana (Faculty of Medicine, Universitas Indonesia), 34 CEA
procedures in all symptomatic patients with 1 until 3 times history of TIA and hypertension
previously, can be performed safely. In the end, we believe that we all share a similar hope that what
we did contributes to the improvement of stroke care in Indonesia. With well-organized strokeemergency transport services, well-educated neurological and vascular expertise especially for
performing medical and surgical will make treatment like Carotid Endarterectomy (CEA) possible
and available for patients.

Keywords: stroke, carotid endarterectomy, stroke prophylaxis, interdisciplinary

References
1.
2.
3.
4.
5.

6.

7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.

Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, et al. Heart disease and stroke statistics 2012 update: a
report from the American Heart Association. Circulation 2012; 125:e2-220.
Molina CA. Reperfusion therapies for acute ischemic stroke: current pharmacological and mechanical approaches.
Stroke 2011; 42:S16-9.
Meyers PM, Schumacher C, Conolly ES, Heyer EJ, Gray WA, Higashida RT. Current status of endovascular stroke
treatment. Circulation 2011; 123:2591-601.
Baker WL, Colby JA, Tongbram V, Talati R, Silverman IE, et al. Neurothrombectomy devices for the treatment of
acute ischemic stroke: state of evidence. Ann Intern Med 2011; 154:243-52.
Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, et al. 2011
ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management
of patients with extracranial carotid and vertebral artery disease: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association,
American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American Collegeof
Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis
Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional
Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery.
Stroke. 2011; 42:e464-e540. [published online Jan 31, 2011]
Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC, et al; on behalf of the American Heart Association
Stroke Council, Council on Cardiovascular Nursing, Council on Clinical Cardiology, and Interdisciplinary Council on
Quality of Care and Outcomes Research. Guidelines for the precention of stroke in patients with stroke or transient
ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke
Association. Stroke 2011; 42:227-76.
Lanzino G, Rabinstein AA, Brown RD. Treatment of Carotid: Medical Therapy, Surgery, or Stenting? Mayo Clinic
Proc. April 2009;84(4):362-368.
Rothwell PM, Giles MF, Chandratheva A, et al; Early use of Existing Preventive Strategies for Stroke (EXPRESS)
study. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS
study): a prospective population-based sequential comparison. Lancet. 2007;370(9596):1432-1442.
Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke
risk after transient ischaemic attack. Lancet. 2007;369(9558):283-292.
Gloviczki P, Roberts JM, Roberts R. Endarterectomy or Stenting for Carotid Artery Disease: Current Evidence and
Guidelines of the Society for Vascular Surgery. 25th World Congress of the International Union of Angiology, July 15, Prague, Check Republic.
Rothwell PM, Warlow CP on behalf of the European Carotid Surgery Trialists Collaborative Group. Prediction of
benefit from carotid endarectomy in individual patients: a risk-modelling study. Lancet. 1999 Jun 19;353(9170):210510.
Barnett HJ, Taylor DW, Eliasziw M, et al; North American Symptomatic Carotid Endarterectomy Trial Collaborators.
Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med.
1998;339(20):1415-1425.
Naylor AR. Delay may reduce procedural risk, but at what price to the patient? Eur J Vasc Endovasc Surg. 2008
Apr;35(4):383-391. Epub 2008 Feb 7.
Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ. Sex difference in the effect of time from symptoms
to surgery on benefit from carotid endarterectomy for transient ischemic attack and nondisabling stroke. Stroke. 2004
Dec;35(12):2855-2861. Epub 2004 Oct 28.
Conrad MF, Kang J, Mukhopadhyay S, Patel VI, LaMuraglia GM, Cambria RP. A Risk Prediction Model for
Determining Appropriateness of CEA in Patients With Asymptomatic Carotid Artery Stenosis. Annals of Surgery.
2013;258(4):534-540.
Badan Penelitian dan Pengembangan Kesehatan Departemen Kesehatan RI. [Laporan nasional riset kesehatan dasar
2007]. Jakarta: Departemen Kesehatan RI; Desember 2008.
Mense L, Reimann M, Rdiger H, Gahn G, Reichmann H, Hentschel H, et al. Autonomic Function and Cerebral
Autoregulation in Patients Undergoing Carotid Endarterectomy. Circ J 2010; 74:2139-49.
Imai Y, Tsuji I, Nagai K, Watanabe N, Ohkubo T, Sakuma M, et al. Circadian Blood Pressure Variation Related to
Morbidity and Mortality from Cerebrovascular and Cardiovascular Diseases. Ann N Y Acad Sci. 1996;783:172-85.
Binici Z, Mouridsen MR, Kber L, Sajadieh A. Decreased nighttime heart rate variability is associated with increased
stroke risk. Stroke. 2011 Nov;42(11):3196-201.
Doux JD and Yun AJ. The link between carotid artery disease and ischemic stroke may be partially attributable to
autonomic dysfunction and failure of cerebrovascular autoregulation triggered by Darwinian maladaptation of the
carotid baroreceptors and chemoreceptors. Med Hypotheses. 2006;66(1):176-81.
Metoki H, Ohkubo T, Kikuya M, Asayama K, Obara T, Hara A. Prognostic significance of night-time, early morning,
and daytime blood pressures on the risk of cerebrovascular and cardiovascular mortality: the Ohasama Study. J
Hypertens. 2006 Sep;24(9):1841-8.