Carotid Wars Episode VI: Return of the Standard

Abstract

In modern medicine, a novel treatment or procedure typically needs decades to demonstrate efficacy compared with the previous standard and to make its way into routine clinical practice. More than 20 years ago, the young Challenger, carotid endarterectomy (CEA), defeated the old Standard, medical treatment, in the battlefields of North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Stenosis Trial (ECST). This victory established a new era of “The Surgical Empire,” and CEA was crowned as the treatment of choice for moderate and severe symptomatic carotid stenosis. However, despite the overall robust benefit from CEA, there were some fronts where the victory was less rotund. Subgroup analysis of pooled data from the large randomized controlled trials (RCTs) showed the lowest degree of benefit from surgery in women, patients 50%, the number needed to treat by CEA increased 4-fold in women, 3-fold in patients aged <65 years, and 25-fold in whom surgery was performed …