Management Of Carotid Artery Disease Research Articles

Symptomatic Nonstenotic Carotids: A Topical Review.

Historically, the management of carotid artery disease has primarily focused on the degree of stenosis as the main indicator for assessing stroke etiology, risk, and need for intervention. However, accumulating evidence suggests that structural and biological features within the arterial wall, such as intraplaque hemorrhage, may have superior diagnostic, prognostic, and therapeutic values. Under current guidelines, unless an atheroma results in ≥50% stenosis, it is not considered the cause of a cerebrovascular event. This results in extensive and often unproductive diagnostic workup, prescription of ineffective medical therapy, and preclusion of patients from receiving revascularization procedures that have been shown to prevent recurrent cerebrovascular events in cases of ≥50% stenosis. A subset of embolic strokes of undetermined source, which account for up to 25% of all ischemic cerebrovascular events, are thought to be due to thromboembolic phenomena from undiagnosed plaque disruptions in nonstenotic arteries (<50% stenosis). Recently, it has been proposed to reclassify this subgroup of patients as symptomatic nonstenotic carotid if the carotid plaque ipsilateral to the cerebrovascular event presents with high-risk features including intraplaque hemorrhage, lipid-rich necrotic core, thinning/rupture of the fibrous cap, and ulceration. In this review, we first provide a historical overview of the chain of events and circumstances that resulted in the present management of carotid artery disease. Second, we embed the contemporary biomarkers of plaque vulnerability in a modern mechanistic paradigm of carotid plaque disruption and thromboembolization. Third, we review the clinically available imaging tools to detect these biomarkers, and how their use has started to shed light on the prevalence and natural history of this underdiagnosed condition. Fourth, we review recent clinical studies employing a contemporary definition of symptomatic nonstenotic carotid and discuss targeted treatments for this condition. Finally, we make a case to generate the much-needed high-level evidence to align the clinical management of patients with symptomatic nonstenotic carotid with a contemporary understanding of plaque disruption and thromboembolization.

The role of ultrasound in the management of carotid artery disease after head and neck radiotherapy treatment

AbstractHead and neck cancers (HNC) are a significant cause of morbidity and mortality globally. Radiotherapy (RT) is used heavily in the treatment of HNCs and has undergone rapid development since the 1980s which has led to increased survival rates in this patient group. Carotid artery stenosis and an increased incidence of stroke and transient ischaemic attack (TIA) have all been repeatedly described as a side effect of head and neck RT with vascular fibrosis implicated in its pathogenesis. The appearance of RT induced carotid stenosis displays a different phenotype to typical atherosclerotic plaque which can be appreciated both in histology samples and on ultrasound imaging. Ultrasound may also have a role to play in screening HNC patients who undergo RT to identify those at risk of suffering cerebrovascular events.

Optimal management of carotid artery disease in patients undergoing coronary artery bypass

Optimal management of carotid artery disease in patients undergoing coronary artery bypass

Clinical outcomes and predictors of acute cerebrovascular strokes after coronary artery bypass graft surgery

Abstract Funding Acknowledgements Type of funding sources: None. Background Coronary artery bypass graft (CABG) surgery still carries a significant risk acute cerebrovascular stroke despite advances in anesthetic, surgical and medical managements. Objective To study the risk factors and get the predictors of acute stroke after CABG and study the clinical outcomes during hospitalization and follow up. Methods This retrospective study included 410 patients who underwent CABG at our tertiary care hospital from January 2016 to August 2020. The patients were divided into two groups according to the occurrence of acute cerebrovascular stroke. Results The study included 410 patients with a median age of 60(55-68) years with a male predominance (82.2%). Thirty-one (7.5%) patients developed strokes after CABG. The stroke group had significantly higher initial sequential organ failure assessment (SOFA) score [ 3(2-4) vs. 2(1-3), p=0.002], SOFA after 48 hours [5(1-7) vs. 1(0-2), p&amp;lt;0.001], higher peak blood lactate level [12.5(7.6-14.7) vs. 5.1(3.7-8.5),p&amp;lt;0.001], longer ICU stay [11(6-42) vs. 4(3-5), p&amp;lt;0.001], more ventilator days [10(2-32) vs. 1(1-2), p&amp;lt;0.001], more tracheostomies (38.7 vs. 0, p&amp;lt;0.001) ,longer post ICU ward stay [11(2-57) vs. 5(3-7), p=0.015] and greater hospital mortality (25.8 vs. 0.8, p&amp;lt;0.001) compared to the non-stroke group respectively. Both groups showed insignificant mortality during a follow up period of 41.5(26.5-54.5) months. Multivariate regression revealed that early hospital stroke was independently predicted with carotid artery disease (OR:8.22, 95%CI:2.92-23.1, p&amp;lt;0.001), CPB time (OR:5.64, 95%CI:1.97-16.11, p&amp;lt;0.001), initial SOFA score (OR:1.643, 95%CI:1.194-2.26, p=0.002), prior stroke (OR:4.412, 95%CI:1.286-15.14, p=0.018), postoperative new AF (OR: 3.014, 95%CI:1.158-7.84, p=0.024) and CKD (OR:1.28,95%CI:1.05-3.75, p=0.017). Late cerebrovascular stroke was independently predicted with CAD (OR:9.38, 95%CI:3.72-23.66, p&amp;lt;0.001), postoperative AF (OR: 2.35,95%CI:1.0125-5.41, p=0.016), prior stroke (OR:3.725,95%CI:1.179-11.768, p=0.025), CABG plus valve surgery (0R:7.44, 95%CI:2.75-20.145, p&amp;lt;0.001), HBA1c (OR:1.431, 95%CI:1.071-1.914, p=0.016) and CKD (OR:2.33, 95%CI:1.056-5.165, p=0.036). Conclusion Acute cerebrovascular stroke is a serious complication after CABG and associated with increased mortality, longer hospital stays with multiple morbidities and resources consumption. Appropriate assessment and management of carotid artery disease, and post-operative atrial fibrillation should be routinely implemented to reduce the risk of early and late strokes in patients undergoing CABG.

A systematic review supporting the Society for Vascular Surgery Guidelines on the management of carotid artery disease.

To support the development of guidelines on the management of carotid disease, a writing committee from the Society for Vascular Surgery has commissioned this systematic review. We searched multiple data bases for studies addressing five questions: medical management vs carotid revascularization (CEA) in asymptomatic patients, CEA vs carotid artery stenting (CAS) in symptomatic low surgical risk patients, the optimal timing of revascularization after acute stroke, screening high-risk patients for carotid disease, and the optimal sequence of interventions in patients with combined coronary and carotid disease. Studies were selected and appraised by pairs of independent reviewers. Meta-analyses were performed when feasible. Medical management compared with carotid interventions in asymptomatic patients was associated with better early outcome during the first 30days. However, CEA was associated with significantly lower long-term rate of stroke/death at 5years. In symptomatic low-risk surgical patients, CEA was associated with a lower risk of stroke, but a significant increase in myocardial infarction compared with CAS during the first 30days. When the long-term outcome of transfemoral CAS vs CEA in symptomatic patients were examined using preplanned pooled analysis of individual patient data from four randomized trials, the risk of death or stroke within 120days of the index procedure was 5.5% for CEA and 8.7% for CAS, which lends support that, over the long term, CEA has a superior outcome compared with transfemoral CAS. When managing acute stroke, the comparison of CEA during the first 48hours to that between day 2 and day 14 did not reveal a statistically significant difference on outcomes during the first 30days. Registry data show good results with CEA performed in the first week, but not within the first 48hours. A single risk factor, aside from peripheral artery disease, was associated with low carotid screening yield. Multiple risk factors greatly increase the yield of screening. Evidence on the timing of interventions in patients with combined carotid and coronary disease was sparse and imprecise. Patients without carotid symptoms, who had the carotid intervention first, compared with a combined carotid intervention and coronary artery bypass grafting, had better outcomes. This updated evidence summary supports the Society for Vascular Surgery clinical practice guidelines for commonly raised clinical scenarios. CEA was superior to medical therapy in the long-term prevention of stroke/death over medical therapy. CEA was also superior to transfemoral CAS in minimizing long-term stroke/death for symptomatic low risk surgical patients. CEA should optimally be performed between 2 and 14days from the onset of acute stroke. Having multiple risk factors increases the value of carotid screening.

Carotid stenosis management: time to address the misconceptions ('furphies').

Improper management of carotid artery disease for stroke prevention is prevalent. Accumulating misconceptions (‘furphies’) drive the overuse of carotid artery procedures and the inappropriate use of medicines. Recognition of these furphies is essential to improve disease management and optimize patient outcomes.

Carotid Restenosis Following Endarterectomy in Patients Managed With Single Antiplatelet Therapy Versus Dual Antiplatelet Therapy

Antiplatelet therapy is a cornerstone in the management of carotid artery disease following carotid endarterectomy (CEA). There is a paucity of data regarding the effect of dual antiplatelet therapy (DAPT) on restenosis rates. A retrospective review of patients who underwent CEA from January 1, 2007 to December 31, 2013 was performed at a single center. Study groups consisted of subjects who received DAPT and those who received single antiplatelet therapy (SAPT) following CEA. Restenosis was evaluated by carotid duplex. Severity and timing of restenosis, postoperative complications, and reinterventions were compared between study groups. Between January 1, 2007 and December 31, 2013, 1453 patients underwent CEA. The SAPT group consisted of 245 patients and the DAPT group consisted of 1208 patients. No difference in restenosis was identified between groups at less than 6 weeks (6.5% vs. 11.7% 50-79% stenosis, 0% vs. 2.2% 80-99% stenosis, 2.2% vs. 0.6% occlusion, p = 0.368), and 6 weeks to 2 years (20.6% vs. 17.9% 50-79% stenosis, 1.1% vs. 1.0% 80-99% stenosis, 1.6% vs. 0.4% occlusion, p = 0.242). A higher rate of restenosis in SAPT was found greater than 2 years from surgery (68.4% vs. 82.4% <50% stenosis, 29.9% vs. 16.1% 50-79% stenosis, 0% vs. 0.6% 80-99% stenosis, 1.7% vs. 0.9% occlusion p = 0.004). This finding persisted on multivariable analysis with 31.6% of the SAPT group showing >50% stenosis vs. 17.6% of the DAPT group (adjusted OR 0.48, 95% CI 0.30-0.76, p = 0.002). In a propensity matched-population, 32.7% of the SAPT group demonstrated restenosis vs. 13.7% of the DAPT group (adjusted OR 0.35, 95% CI 0.16-0.77, p = 0.009). There was no difference in the need for reintervention between study groups (DAPT 3.8% vs SAPT 3.3%, p = 0.684). Following CEA, patients on DAPT exhibited lower rates of late restenosis. Despite this finding, a clinical difference in reintervention was not found during this study period.

Diagnostic and Therapeutic Management of Carotid Artery Disease

Diagnostic and Therapeutic Management of Carotid Artery Disease Abstract. A quarter of all ischemic strokes is caused by atherosclerotic obliterations of the extra- and intracranial brain-supplying vessels. The prevalence of atherosclerotic extracranial carotid stenosis rises up to 6-15 % from the age of 65. The risk of stroke in symptomatic carotid stenosis, i.e. after stroke or transient ischemic attack (TIA), is very high at 25 % within 14 days. Conservative therapy is the cornerstone of treatment by controlling the risk factors, treatment with platelet aggregation inhibitors and antihypertensive and lipid-lowering medication. Carotid endarterectomy (CEA) is the first line treatment for symptomatic patients with a >50 % and asymptomatic patients with a >60 % carotid stenosis. In order to ensure the best possible treatment of patients with asymptomatic and symptomatic carotid stenosis, interdisciplinary cooperation in diagnostics, therapy and aftercare in a neuromedical centre of maximum care is necessary.

A promising tool to tackle the risk of cerebral vascular disease, the emergence of novel carotid wall imaging.

Stroke is a heterogeneous vascular disease. Carotid artery atherosclerosis is associated with almost one-quarter of ischemic strokes. Moreover, a large percentage of preventable strokes are currently attributed to carotid atherosclerosis. Over the past three decades, the management of carotid artery disease has evolved. The benefits of carotid revascularization alongside medical therapy have early been recognized. Nonetheless, the debate regarding the optimal strategy is still ongoing, particularly in patients with asymptomatic carotid artery disease. One of the challenges is the use of luminal stenosis to quantify the severity of the carotid artery disease and to guide decision-making regarding invasive revascularization. Characterizing carotid atherosclerotic plaque is a promising tool to identify vulnerable plaque. Certain features such as large lipid core have already been linked to acute vascular events, not only at the plaque level but also to predict systemic cardiovascular events. Recently, a quantitative T2 mapping magnetic resonance imaging technique was developed and validated against histology. The ability to accurately quantify plaque lipid content using this technique opens several new opportunities. In this review articles, we will discuss the current challenges in the management of carotid artery disease and the future roles of T2 mapping to aid therapeutic options. These roles may include how to determine the mode of invasive carotid revascularization in symptomatic patients. Moreover, there may be a rational to use T2 mapping as a risk stratification tool in asymptomatic patients with carotid artery stenosis. It may also provide an opportunity to stage atherosclerosis and identify patients with coronary atherosclerosis who may benefit maximally from intensive lipid interventions.

An Analysis of Malpractice Litigation in the Surgical Management of Carotid Artery Disease

Objective Carotid artery disease is a common illness that can pose a significant risk if left untreated. Treatment via carotid endarterectomy (CEA) or carotid artery stenting (CAS) can also lead to complications. Given the risk of adverse events related to treating, or failing to treat, carotid artery disease, this is a possible area for litigation. The aim of this review is to provide an overview of the medicolegal factors involved in treating patients suffering carotid artery disease and to compare litigation related to CEA and CAS. Methods Three large legal databases were used to search for jury verdicts and settlements in cases related to untreated carotid artery disease, CEA, and CAS. Search terms included endarterectomy, medical malpractice, carotid, stenosis, stenting, stent, and combinations of those words. Three types of cases were considered relevant: 1) cases in which the primary allegation was negligence performing a CEA or perioperative care (CEA-related cases); 2) cases in which the primary allegation was negligence performing a CAS or perioperative care (CAS-related cases); and 3) cases in which the plaintiff alleged that a CEA or CAS should have been performed (failure-to-treat [FTT] cases). Results One hundred fifty-four CEA-related cases, 3 CAS-related cases, and 67 FTT cases were identified. Cases resulted in 133 verdicts for the defense (59%), 64 settlements (29%), and 27 plaintiff verdicts (12%). The average payout in cases that were settled outside of court was $1,097,430 and the average payout in cases that went to trial and resulted in a plaintiff verdict was $2,438,253. Common allegations included a failure to diagnose and treat carotid artery disease in a timely manner, treating with inappropriate indications, procedural error, negligent postprocedural management, and lack of informed consent. Allegations of a failure to timely treat known carotid artery disease were likely to lead to a payout (60% of cases involved a payout). Allegations of procedural error, specifically where the resultant injury was nerve injury, were relatively less likely to lead to a payout (28% of cases involved a payout). Conclusions Both diagnosing and treating carotid artery disease has serious medicolegal implications and risks. In cases resulting in a plaintiff verdict, the payouts were significantly higher than cases resolved outside the courtroom. Knowledge of common allegations in diagnosing and treating carotid artery disease as well as performing CEA and CAS may benefit neurosurgeons. The lack of CAS-related litigation suggests these procedures may entail a lower risk of litigation compared to CEA, even accounting for the difference in the frequency of both procedures.

An analysis of malpractice litigation in the surgical management of carotid artery disease.

Carotid artery disease is a common illness that can pose a significant risk if left untreated. Treatment via carotid endarterectomy (CEA) or carotid artery stenting (CAS) can also lead to complications. Given the risk of adverse events related to treating, or failing to treat, carotid artery disease, this is a possible area for litigation. The aim of this review is to provide an overview of the medicolegal factors involved in treating patients suffering carotid artery disease and to compare litigation related to CEA and CAS. Three large legal databases were used to search for jury verdicts and settlements in cases related to untreated carotid artery disease, CEA, and CAS. Search terms included "endarterectomy," "medical malpractice," "carotid," "stenosis," "stenting," "stent," and combinations of those words. Three types of cases were considered relevant: 1) cases in which the primary allegation was negligence performing a CEA or perioperative care (CEA-related cases); 2) cases in which the primary allegation was negligence performing a CAS or perioperative care (CAS-related cases); and 3) cases in which the plaintiff alleged that a CEA or CAS should have been performed (failure-to-treat [FTT] cases). One hundred fifty-four CEA-related cases, 3 CAS-related cases, and 67 FTT cases were identified. Cases resulted in 133 verdicts for the defense (59%), 64 settlements (29%), and 27 plaintiff verdicts (12%). The average payout in cases that were settled outside of court was $1,097,430 and the average payout in cases that went to trial and resulted in a plaintiff verdict was $2,438,253. Common allegations included a failure to diagnose and treat carotid artery disease in a timely manner, treating with inappropriate indications, procedural error, negligent postprocedural management, and lack of informed consent. Allegations of a failure to timely treat known carotid artery disease were likely to lead to a payout (60% of cases involved a payout). Allegations of procedural error, specifically where the resultant injury was nerve injury, were relatively less likely to lead to a payout (28% of cases involved a payout). Both diagnosing and treating carotid artery disease has serious medicolegal implications and risks. In cases resulting in a plaintiff verdict, the payouts were significantly higher than cases resolved outside the courtroom. Knowledge of common allegations in diagnosing and treating carotid artery disease as well as performing CEA and CAS may benefit neurosurgeons. The lack of CAS-related litigation suggests these procedures may entail a lower risk of litigation compared to CEA, even accounting for the difference in the frequency of both procedures.

Abstract WMP39: Laser Angioscopy in Carotid Artery Disease: Imaging Findings and Histopathological Correlation

Our understanding and management of carotid artery disease has largely relied on angiography, US and MR. However, existing modalities cannot accurately identify the spectrum of thrombogenic lesions on the vascular surface or reliably detect structural markers of instability. Thus, the natural history of the different histopathological hallmarks of advanced or complicated plaques is unknown, and many patients with culprit substenotic plaques are misdiagnosed with cryptogenic stroke. An intraluminal approach to directly inspect the endovascular surfaces at unprecedented resolutions would enable detailed structural analysis of carotid plaques and the identification of the root cause of carotid-related strokes. A scanning fiber angioscope (SFA), a high-definition 1.2-mm forward-viewing camera that generates videos by spirally scanning low-power laser beams, was developed for clinical use and employed to analyze the endovascular surfaces of ex vivo human carotid arteries (n=95) and endarterectomized plaques (n=20). Specimens were then imaged with US and micro-CT, and all vascular diagnostic tests obtained in the patients undergoing carotid revascularization were accessed. Imaging findings in the vascular surfaces were then validated by histomorphological analysis of &gt;300 lesions, and an angioscopic classifier for atherosclerosis was generated. Full-color videos at 30Hz and at a resolution &gt;200,000 pixels were generated from the entire endovascular circumference in all specimens with depth-of-focus larger than 5cm in saline solution. The ability to analyze the surface anatomy with unparalleled detail allowed the identification of early, intermediate, advanced and complex atherosclerotic lesions, including ulceration of fibrotic cap, excavation of the necrotic core leading to pseudolumens, intimal flaps, exposed necrotic core to the lumen, erosions, recent and remote intimal hemorrhages, luminal thrombus, eruptive calcified nodules and calcified intimal sheaths and plates. SFA offers a direct view of the endoluminal surfaces with unparalleled resolution and has the potential to revolutionize research, diagnosis, prognosis and image-guided therapy in carotid atherosclerosis.

Imaging Carotid Atherosclerosis Plaque Ulceration: Comparison of Advanced Imaging Modalities and Recent Developments

Atherosclerosis remains the leading cause of long-term mortality and morbidity worldwide, despite remarkable advancement in its management. Vulnerable atherosclerotic plaques are principally responsible for thromboembolic events in various arterial territories such as carotid, coronary, and lower limb vessels. Carotid plaque ulceration is one of the key features associated with plaque vulnerability and is considered a notable indicator of previous plaque rupture and possible future cerebrovascular events. Multiple imaging modalities have been used to assess the degree of carotid plaque ulceration for diagnostic and research purposes. Early diagnosis and management of carotid artery disease could prevent further cerebrovascular events. In this review, we highlight the merits and limitations of various imaging techniques for identifying plaque ulceration.

PERFORMING TRANSCATHETER AORTIC VALVE IMPLANTATION IN PATIENTS WITH CAROTID STENOSIS

The management of carotid artery disease in patients with severe aortic stenosis referred for transcatheter aortic valve implantation is challenging. By reviewing the very limited amount of literature we will try to answer the question should we perform carotid revascularization before or after the TAVI procedure.

Plaque Imaging to Decide on Optimal Treatment: Medical Versus Carotid Endarterectomy Versus Carotid Artery Stenting.

Many of the current guidelines for the management of carotid atherosclerosis are based on clinical trial findings published more than 2 decades ago. The lack of plaque information in clinical decision making represents a major shortcoming and highlights the need for contemporary trials based on characteristics of the atherosclerotic lesion itself, rather than luminal stenosis alone. This article summarizes the major dilemmas clinicians face in current practice, and discusses the rationale and evidence that plaque imaging may help to address these challenges and optimize the clinical management of carotid artery disease in the future.

Intravascular Near-Infrared Spectroscopy: A Possible Tool for Optimizing the Management of Carotid Artery Disease.

Stroke is the second most common cause of morbidity and mortality in the Western nations. It is estimated that approximately one-fifth of all strokes or transient ischemic attacks are caused by carotid artery disease. Thus, treatment of carotid artery disease as a mean of stroke prevention is extremely important. Since the introduction of carotid endarterectomy, debate has persisted over the treatment strategy for carotid artery disease. Current recommendations have many potential flaws because they are often based on older trials performed before the introduction of modern pharmacotherapy and are mostly based on the angiographic degree of stenosis, without an emphasis on the pathophysiology of the disease. Most carotid events are caused by rupture or distal embolization of the content of an unstable atherosclerotic plaque with a large lipid pool. Thus, it is plausible that the information regarding the composition of the atherosclerotic plaque could play an important role in deciding on a treatment strategy. In this review article, we provide information about near-infrared spectroscopy, a new invasive imaging modality, which seems to be capable of providing such information.

The association between preoperative clinical risk factors and in-hospital strokes and death following carotid endarterectomy in South African patients

Background: Current surgical management of carotid artery disease includes carotid endarterectomy (CEA). In-hospital strokes and death following CEA might be associated with preinduction blood pressure (BP) measurements and other clinical risk factors.Method: The aim of our study was to determine whether or not there is an association between preinduction BP, other clinical risk factors, and in-hospital strokes or death following CEA in a cohort of South African patients. We collected data from medical records relating to clinical risk factors in patients, preinduction BP measurements, and in-hospital strokes and death, following CEA. The association between preinduction BP and clinical risk factors, and postoperative neurological morbidity and mortality, was analysed using univariate statistical methods.Results: Our cohort consisted of 76 patients who underwent CEA. Eight of these patients had in-hospital strokes or death following their surgery. An association between a history of hypertension or other ...

The current management of carotid atherosclerotic disease: who, when and how?

Ischaemic stroke represents a major health hazard in the western world, which has a severe impact on society and the health-care system. Roughly, 10% of all first ischaemic strokes can be attributed to significant atherosclerotic disease of the carotid arteries. Correct management of these lesions is essential in the prevention and treatment of carotid disease-related ischaemic events. The close relationship between diagnosis and medical and surgical management makes it necessary that all involved physicians and surgeons have profound knowledge of management strategies beyond their specific speciality. Continuous improvement in pharmacological therapy and operative techniques as well as frequently changing guidelines represent a constant challenge for the individual health-care professional. This review gives a thorough outline of the up-to-date evidence-based management of carotid artery disease and discusses its current controversies.

Advances in the Management of Carotid Artery Disease: Focus on Recent Evidence and Guidelines

Recent landmark randomized trials and society guidelines have significantly revised the management of carotid artery disease. Duplex ultrasonography is the recommended initial diagnostic test for the assessment of extracranial carotid artery stenosis. Carotid artery imaging is reasonable in select patients scheduled for coronary artery bypass graft (CABG) surgery. Carotid revascularization can be achieved safely and effectively with carotid endarterectomy or carotid artery stenting. Because each procedure has a different risk/benefit profile, the optimal approach is to match the particular patient to the intervention that maximizes outcome benefit. Carotid revascularization is recommended in patients scheduled for CABG surgery when the carotid artery stenosis is symptomatic and/or bilateral. Further trials are required to guide the management of asymptomatic unilateral carotid artery stenosis in patients undergoing CABG surgery. Aggressive medical therapy remains the gold standard for intracranial carotid artery disease because landmark trials have shown no outcome improvement with vascular bypass or percutaneous angioplasty and stenting. A large recent trial showed that local anesthesia, as compared with general anesthesia, for carotid endarterectomy has no major clinical outcome advantage. Although carotid artery stenting is associated with a reduced risk of myocardial ischemia, it still has important risks of stroke and hemodynamic instability that significantly affect clinical outcome. The timing and choice of carotid revascularization technique ultimately depends on multiple clinical factors.

Influence and Critique of CREST and ICSS Trials

The principle findings of the Carotid Revascularization Endarterectomy Versus Stenting Trial and the International Carotid Stenting Study are reviewed and discussed. Flaws and possible weaknesses in both trials are highlighted. The possibility that some Carotid Revascularization Endarterectomy Versus Stenting Trial conclusions have been misinterpreted in ways not justified by the trial's data is considered. This possibility may have prompted one conclusion of a recent American Heart Association Guideline on the management of carotid artery disease to be misleading.