Pro: Carotid Angioplasty and Stenting Will Be the First-Line Interventional Therapy for Stroke Prevention in Patients With Extracranial Carotid Occlusive Disease

Abstract

CAROTID ENDARTERECTOMY (CEA) is the most thoroughly studied of all vascular surgical procedures. There is level I evidence from 4 randomized studies in a total of 12,000 patients that shows that in properly selected patients CEA can reduce the relative risk of stroke by approximately 50% in both symptomatic and asymptomatic patients when compared with medical management. 1 Executive Committee for the Asymptomatic Carotid Atherosclerosis StudyEndarterectomy for asymptomatic carotid artery stenosis. JAMA. 1995; 273: 1421 Crossref PubMed Scopus (5103) Google Scholar , 2 North American Symptomatic Carotid Endarterectomy Trial CollaboratorsBeneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991; 325: 445-453 Crossref PubMed Scopus (7773) Google Scholar , 3 Ferguson G.G. Eliasziw M. Barr H.W.K. et al. The North American Symptomatic Carotid Endarterectomy Trial Surgical results in 1415 patients. Stroke. 1999; 30: 1751-1758 Crossref PubMed Scopus (877) Google Scholar , 4 ECST GroupRandomized trial of endarterectomy for recently symptomatic carotid stenosis Final results of the MRC European Carotid Surgery Trial (ECST). Lancet. 1998; 351: 1379-1387 Abstract Full Text Full Text PDF PubMed Scopus (2915) Google Scholar In a pooled analysis of 6,092 symptomatic patients from the NASCET, ECST, and VA studies, patients with symptomatic 50% to 69% stenosis had a 4.6% absolute risk reduction in stroke over 5 years and patients with stenosis of 70% to 99% had a reduction of 16% when compared with medical management. 2 North American Symptomatic Carotid Endarterectomy Trial CollaboratorsBeneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991; 325: 445-453 Crossref PubMed Scopus (7773) Google Scholar , 3 Ferguson G.G. Eliasziw M. Barr H.W.K. et al. The North American Symptomatic Carotid Endarterectomy Trial Surgical results in 1415 patients. Stroke. 1999; 30: 1751-1758 Crossref PubMed Scopus (877) Google Scholar , 5 Barnett H.J. Taylor D.W. Eliasziw M. et al. North American Symptomatic Carotid Endarterectomy Trail CollaboratorsBenefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med. 1998; 339: 1415-1425 Crossref PubMed Scopus (2971) Google Scholar In 4,072 asymptomatic patients from the ACAS and ACST trials, patients with a stenosis of >60% had an absolute stroke risk reduction of 5.5% when compared with medically treated patients. 1 Executive Committee for the Asymptomatic Carotid Atherosclerosis StudyEndarterectomy for asymptomatic carotid artery stenosis. JAMA. 1995; 273: 1421 Crossref PubMed Scopus (5103) Google Scholar , 6 Halliday A. Mansfield A. Marro J. et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms Randomised controlled trial. Lancet. 2004; 363: 1491-1502 Abstract Full Text Full Text PDF PubMed Scopus (2090) Google Scholar It is clear that CEA works when performed by well-trained surgeons in properly selected patients. On the other hand, the data available to define the benefits of carotid angioplasty and stenting (CAS) in the treatment of patients with extracranial carotid occlusive disease in no way compare to that available for CEA. The data that are available at best suggest that CAS may be comparable to CEA in high-risk patients and more often than not have shown that CAS is inferior to CEA, even in the high-risk patient population. Despite the present lack of data, the author believes that within the next 5 years CAS will become the default first-line therapy for the treatment of patients with extracranial carotid occlusive disease. The explanations for this projected shift in treatment paradigms include patient and referring physician desire, the increasing interest of cardiologists in treating cerebrovascular disease, and continued refinements in CAS-related technology.