Are There Patients Truly at High-Risk for Carotid Endarterectomy or Carotid Stenting? Can They Be Identified?

Abstract

The field of carotid artery revascularization has seen dramatic changes during the past several years, with emergence of carotid artery stenting (CAS) as a treatment alternative to surgical carotid endarterectomy (CEA). CAS enthusiasts have argued that all North American Symptomatic Carotid Endarterectomy Trial (NASCET)-excluded patients are at high-risk (HR) for CEA and, therefore, should be offered stenting instead, accepting or proposing-by implication-that CAS would achieve a better outcome than surgery. The latter is, of course, completely unproved, and the former can be easily refuted through a current reexamination of such NASCET exclusions and of CEA results in contemporary vascular surgery. HR for CEA does exist, however, and relates mainly to anatomic factors, such as hostile neck situations, carotid artery anatomy, and the nature of the carotid lesion. Some serious medical comorbidities constitute valid HR considerations as well. HR for CAS constitutes the "flip-side" of the above-described. Rapidly accumulating evidence points to the fact that certain patients do poorly with carotid stenting, mainly those with recent symptoms of ipsilateral cerebral ischemia, the elderly, and when arch and carotid artery anatomy are unfavorable for endovascular intervention. At present, CEA remains the standard of care for these and the majority of patients with an appropriate indication for carotid revascularization. Despite the general tone of this article and the type of evidence presented, CAS should still be thought of as a very important addition to our armamentarium. But, today it is a procedure to be applied cautiously and only for the right reasons. On the other hand, CAS techniques and technologies will continue to improve and be refined, especially in the areas of access and embolic protection. In the future, we should not be surprised if CAS ultimately reaches a truly competitive level with CEA.