Will carotid stenting eclipse carotid endarterectomy and, if so, when and how?

Treatment of carotid artery stenosis to prevent stroke ranks amongst the most significant roles for vascular surgeons and specialists as a whole. Carotid endarterectomy (CEA) is the acknowledged standard of care, and is based on solid scientific evidence. However, its pedestal position has been challenged on several fronts, mainly because approximately 20% of such operations are performed on patients who may be at high-risk for poor outcomes (or higher than usual complications) owing to unfavorable factors related to anatomical and/or medical comorbidity factors. Additionally, and as attitudes towards less invasion reach the carotid territory, CEA is increasingly viewed with some suspicion (and even disdain) by those who glorify everything endovascular simply for being so. The result is that percutaneous carotid-stent intervention has evolved into a formidable competitor to CEA. But it will not have a free ride. While it is arguably true that the high-risk territory has been conquered by carotid angioplasty stenting (CAS), the bulk of the CEA market remains unaffected. Treatment of nonhigh-risk patients with CAS remains highly controversial and essentially unproven, especially for those who are asymptomatic. CEA remains the only intervention whose application is based on level 1 evidence. Thus, it would be fair to say that rise of CAS to domination has a long way to go.