Endarterectomy or carotid artery stenting: the quest continues

Carotid endarterectomy (CEA) is still considered the "gold-standard" of the treatment of patients with significant carotid stenosis and has proven its value during past decades. However, endovascular techniques have recently been evolving. Carotid artery stenting (CAS) is challenging CEA for the best treatment in patients with carotid stenosis. This review presents the development of CAS according to early reports, results of recent randomized trials, and future perspectives regarding CAS.

A literature search using the PubMed and Cochrane databases identified articles focusing on the key issues of CEA and CAS.

Early nonrandomized reports of CAS showed variable results, and the Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy trial led to United States Food and Drug Administration approval of CAS for the treatment of patients with symptomatic carotid stenosis. In contrast, recent trials, such as the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial and the Endarterectomy Versus Stenting in Patients with Symptomatic Severe Carotid Stenosis trial, (re)fuelled the debate between CAS and CEA. In the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial, the complication rate of ipsilateral stroke or death at 30 days was 6.8% for CAS versus 6.3% for CEA and showed that CAS failed the noninferiority test. Analysis of the Endarterectomy Versus Stenting in Patients With Symptomatic Severe Carotid Stenosis trial showed a significant higher risk for death or any stroke at 30 days for endovascular treatment (9.6%) compared with CEA (3.9%). Other aspects-such as evolving best medical treatment, timely intervention, interventionalists' experience, and analysis of plaque composition-may have important influences on the future treatment of patients with carotid artery stenosis.

CAS performed with or without embolic-protection devices can be an effective treatment for patients with carotid artery stenosis. However, presently there is no evidence that CAS provides better results in the prevention of stroke compared with CEA.