Treatment for routine symptomatic carotid bulb atherosclerosis

Abstract

![Graphic][1] Symptomatic internal carotid artery (ICA) stenosis is a common cause of ischemic stroke. The goal of management is to decrease the risk of stroke. This objective can be reached with a combination of medical therapy and revascularization with either carotid endarterectomy (CEA) or carotid artery stenting (CAS). At this time, evidence-based medicine provides guidance for our decision regarding which revascularization procedure is the most appropriate for the patient with routine, symptomatic carotid stenosis, i.e., with no clinical or radiographic exclusions for either procedure. The choice of treatment for revascularization comes down to 3 questions: 1) If the goal is to reduce stroke, which treatment option provides the best short and long-term outcomes? 2) Which treatment is cost-effective? 3) Which treatment provides the best patient-centered outcomes? Two recent trials evaluating the difference between CEA and CAS are the Carotid Revascularization Endarterectomy vs Stent Trial (CREST)1 and the International Carotid Stenting Study (ICSS).2 In CREST, the primary composite endpoint of any stroke, myocardial infarction (MI), or death within 30 days following treatment plus any ipsilateral stroke during long-term follow-up (median 2.5 years) was similar for CAS and CEA (7.2% vs 6.8%, hazard ratio [HR] 1.1, 95% confidence interval [CI] 0.8–1.5). There was no differential treatment effect according to symptomatic status. In contrast, the ICSS interim safety analysis evaluating the 120-day rate of stroke, death, or procedural MI reported that more patients in the CAS group reached the combined endpoint of stroke, MI, or death than the CEA group (8.5% vs 5.2%, HR 1.69, 95% CI 1.16–2.45, p = 0.006).2 In addition, a subanalysis of 231 patients in ICSS underwent MRI and demonstrated more ischemic brain lesions on diffusion-weighted imaging after treatment with CAS than … [1]: /embed/inline-graphic-1.gif