Extracranial carotid artery stenosis

Carotid endarterectomy is the most common surgical procedure used to treat stenosis of the extracranial precerebral carotid artery. Data from several randomized controlled trials are available to help guide its use in specific patient subgroups. Carotid angioplasty with stenting is also being performed, and clinical trials comparing this procedure with carotid endarterectomy are in progress.

For patients with symptomatic high-grade (ie, 70% to 99%) stenosis, carotid endarterectomy is associated with an overall benefit (risk ratio estimate for the combined end point of nonfatal stroke, nonfatal myocardial infarction, or death, 0.67; 95% CI, 0.54 to 0.83). The benefit is more modest for patients with less severe stenosis (ie, 50% to 69%) and may vary with specific patient characteristics. Selected patients with asymptomatic carotid stenosis may also benefit from the operation, but it needs to be performed with very low complication rates, which can be difficult to achieve in clinical practice. Several studies of angioplasty, angioplasty with stenting, and more recently angioplasty with stenting and a so-called distal protection device have also been performed. The technology involved continues to evolve rapidly, presenting a challenge for the design and conduct of clinical trials.

Surgical intervention for extracranial carotid stenosis remains a major potential therapeutic modality for the prevention of stroke in selected patients. Endovascular approaches continue to be evaluated in ongoing trials.