Competitive strategies for surgery in the treatment of primary internal carotid artery (ICA) stenosis

Abstract

BACKGROUND: Surgery remains the gold standard in the treatment of internal carotid artery (ICA) stenosis. In the last 10 years endovascular treatment of ICA lesions by carotid artery stenting (CAS) has become increasingly popular. The aim of this study is to assess the arguments of carotid endarterectomy (CEA) adversaries (increased physical stress for the patient, complicated procedure, higher mortality, etc.) and to present modern strategies, by which CEA as competitive treatment modality is able to withstand the current trend towards endovascular management of ICA stenosis. METHODS: Medline (1995–2007) and Cochrane Electronic Databases (2007) were searched for prospectively randomized publications, dealing with surgical and endovascular treatment of ICA stenosis. The results have been evaluated in terms of a meta-analysis and compared according to their different domains (mortality, stroke rate, complications, hospital stay, and costs). Corresponding to these data strategies for successful and safe carotid surgery have been developed. RESULTS: Whereas CEA has proved its efficacy in the treatment of ICA stenosis by large randomized multicenter trials, same Level I data are lacking on endovascular management. Some studies comparing CEA with CAS had to be terminated prematurely because of significant higher rates of neurological complications in the CAS arm. At present there exist no prospectively randomized trials which favour CAS over CEA. CONCLUSIONS: Eversion CEA as fast, safe, relatively easy, and economic procedure in locoregional anesthesia fulfils most demands of modern and competitive surgery. Additionally the length of hospital stay can be reduced significantly. Endovascular treatment of ICA stenosis represents an alternative to CEA only in patients with recurrent ICA stenosis and with hostile necks.