[Internal carotid artery revascularization]

Carotid endarterectomy remains the standard revascularization technique for the prevention of ischemic stroke resulting from severe carotid stenosis. Surgery is highly beneficial in patients with a symptomatic stenosis of 70% or greater that is not a total or near-total occlusion. The benefit becomes more diluted in patients with a symptomatic 50-69% stenosis, and surgery has no effect, or even increases the risk of stroke, in those with a less than 50% stenosis. Surgery has also been shown to reduce the risk of stroke in asymptomatic patients with a 60-99% stenosis, but the absolute benefit is only 1% per year. There is no clear evidence that surgery benefits asymptomatic women at 5-year follow-up, and the benefit is unknown in asymptomatic patients aged over 75 years. Decision-making must take individual factors into consideration, particularly in patients with an asymptomatic (60-99%) or a moderate (50-69%) symptomatic carotid stenosis, so that the risk-benefit ratio of surgery can be optimized. Current data do not support the preferential use of carotid stenting over carotid endarterectomy in patients with a symptomatic or asymptomatic carotid stenosis who are good candidates for surgery. In those who are not good surgical candidates, carotid stenting might be equivalent to surgery, but whether or not any form of carotid revascularization is superior to medical treatment alone remains unknown.