Endarterectomy and stenting for asymptomatic carotid stenosis: a race at breakneck speed

Atherosclerotic carotid stenosis has been recognized for the past several decades as being responsible for a significant portion of ischemic stroke, particularly the major and disabling ones. This category of stroke distinguished itself as being one of the first ones to have an effective preventive treatment in carotid endarterectomy. It took over 4 decades before major randomized, controlled trials were completed in North America and Europe to provide enough definitive information about its effectiveness, risks, limitations, and categories of patients that most benefit from it. Just like any invasive surgery, endarterectomy is being challenged by minimally invasive stenting, which has already made major technologic leaps and rapid clinical inroads. Stenting has started by tackling patient populations like surgical high-risk patients who were largely avoided in the endarterectomy trials and demonstrated equivalence to it in such populations. The broader applicability of the technique, however, has not been yet adequately investigated. The results so far are greatly reassuring and encouraging to enroll patients in the ongoing randomized trials that will hopefully provide more definitive answers to this issue.