Managing carotid stenosis: carotid endarterectomy and stenting

Carotid artery stenosis is one of many risk factors of stroke and transient ischaemic attack. Asymptomatic and symptomatic carotid stenoses behave differently and they should be considered as different disease entities. This review provides an up-to-date overview of the evidence base for the management of patients with asymptomatic and symptomatic carotid stenosis. Two landmark trials have established carotid endarterectomy as the standard treatment of severe (>70%) symptomatic carotid stenosis. In moderate symptomatic stenosis (50-69%) and increasing time since onset of symptoms the benefit is much less. Medical treatment has undergone marked improvement since the trials have been conducted which should be kept in mind when interpreting these trials. Factors such as recency and nature of symptoms, age, sex and severity of stenosis need to be taken into account when considering intervention. Early trials of endovascular treatment suggested that endovascular treatment may be equally effective as surgery, but subsequent trials have shown very mixed results and offering carotid stenting routinely is not recommended. In patients with asymptomatic carotid stenosis, two landmark trials have shown benefit of surgery over medical treatment particularly in young men. Again it has to be kept in mind that medical treatment has much improved since the surgery trials were conducted.