Treatment for routine, symptomatic, carotid bulb atherosclerosis: Carotid endarterectomy and stenting are comparable.

Abstract

![Graphic][1] The results of recent carotid artery stenting (CAS) vs carotid endarterectomy (CEA) randomized studies (CREST,1 SPACE,2 EVA3S,3 and ICSS4) have created conflict among surgical and endovascular communities over which procedure is preferred for secondary stroke prevention for symptomatic carotid stenosis. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) established CEA as the gold standard for surgical treatment in the early 1990s. Carotid stenting has been held to the high standard of CEA, and in order to present a viable alternative surgical therapy, it must be effective at preventing strokes, durable, and safe, with complication rates comparable to CEA. Carotid stenting is a clinically effective procedure. CREST, SPACE, and EVA3S showed equivalent annual stroke rates for the 2 treatments in symptomatic patients after the initial 30 days (CEA vs CAS: 0.8 vs 0.6, 1.3 vs 1.4, and 0.7 vs 0.4, percent per year, respectively). The stroke-free survival curves in CREST for CEA and CAS are parallel after the perioperative period out to 4 years, indicating clinical durability. > The increase in minor stroke in the CAS group and the increase in perioperative MI in the CEA group offset one another, leading to the equivalent primary endpoint. Perioperative safety remains the controversial point; the 30-day stroke and death rate for the stented patients was over 2 times that of the surgical group in the EVA3S trial. In the ICSS trial, the CAS group suffered stroke or death twice as often as the CEA group. Complications rates were, at best, equivalent in the 2 groups in the SPACE trial (6.3% for CEA and 6.8% for CAS), with CAS not achieving noninferiority. Why the … [1]: /embed/inline-graphic-1.gif