Abstract
Carotid revascularization with carotid endarterectomy (CEA) has been shown to be superior to medical therapy for stroke prevention in symptomatic and asymptomatic patients with moderate to severe stenosis who meet well defined medical and surgical selection criteria. The benefit of CEA is significantly higher in symptomatic compared to asymptomatic patients. Carotid artery stenting (CAS) has emerged as an alternative in patients who are considered high surgical-risk due to co-existent medical co-morbidities or anatomical high-risk features. Since its development in the early 1990’s, the technique of endovascular carotid revascularization has been undergoing a continuous maturation process mainly due to a change from the initial use of balloon expandable stents to self-expanding stents, the introduction of and continuously improving array of emboli prevention devices (EPD's) and last but not least increasing operator experience. This culminated in the randomized SAPPHIRE trial of protected CAS [i.e., CAS performed with EPD] vs. CEA in high surgical-risk patients, that showed that CAS was non-inferior to CEA with lower peri-procedural complication rates as well as lower rates of restenosis (Yadav et al., 2004). Furthermore, increased experience with this technique has led to the realization that just like with CEA, there are patients (e.g., older age, excessive vascular tortuosity or calcification) who are high-risk for CAS. (Chaturvedi et al., 2010).
Highlights
Carotid revascularization with carotid endarterectomy (CEA) has been shown to be superior to medical therapy for stroke prevention in symptomatic and asymptomatic patients with moderate to severe stenosis who meet well defined medical and surgical selection criteria
The question of whether Carotid artery stenting (CAS) is an alternative to CEA in patients without high surgical-risk, is addressed by the results of three randomized, European studies comparing CEA to CAS in patients without high surgical-risk medical or anatomical features (Mas et al, 2006; Ringleb et al, 2006; Ederle et al, 2010) (EVA-3S, SPACE, ICSS)
Following publication of the EVA3s manuscript it was revealed that only 16% of patients were treated by operators with more than 50 CAS cases of experience and 39% of patients were treated by physicians in training (Clark, 2010)
Summary
Carotid revascularization with carotid endarterectomy (CEA) has been shown to be superior to medical therapy for stroke prevention in symptomatic and asymptomatic patients with moderate to severe stenosis who meet well defined medical and surgical selection criteria. As aortic arch tortuosity is emerging as one of the critical factors determining procedural risk with CAS, lack of proof of experience with carotid catheterization as a prerequisite for participation in the trial seen across all the European studies is arguably the most important factor responsible for the overall high rates of stroke reached in these studies.
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