Conversion to carotid artery stenting after neurological intolerance at cross-clamping during carotid endarterectomy: is it a safe option?

Introduction: In the case of intolerance to cross-clamping (CC) during carotid endarterectomy (CEA), the method-of-choice is to place a shunt and continue the procedure. However, some centers abandon open carotid revascularization in case of CC intolerance and perform conversion to carotid artery stenting (CAS). This approach remains controversial and is not accepted by many clinicians.

Evidence acquisition: PubMed, Embase, Web of Science and Cochrane databases were searched for reports published over the last 15 years (2010-2025) regarding conversion to CAS after neurological intolerance to CC during CEA.

Evidence synthesis: Carotid CC intolerance may develop in around 10% of patients undergoing CEA under locoregional anesthesia. There is some evidence that patients who develop CC intolerance may have higher degrees of contralateral carotid stenosis and a higher incidence of perioperative cerebrovascular events compared with individuals who do not develop neurological symptoms after CC. Conversion to CAS may be an alternative to usage of a shunt.

Conclusions: The occurrence of carotid CC intolerance during CEA may be a reason to abandon the procedure and convert to CAS. Nonetheless, the evidence on this topic is not robust, as it is based on small, single-center studies. A multicenter study may provide better-quality evidence in the future.