Carotid stenting vs endarterectomy: new results in perspective
William J Perkins1, Guiseppe Lanzino, Thomas G Brott
1Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. perkinsw@mayo.edu
Insights
Carotid artery stenosis treatments, including carotid endarterectomy (CEA) and stenting (CAS), are compared. Recent large trials show similar outcomes for CEA and CAS in stroke prevention for most patients.
Area of Science:
- Neurology
- Vascular Surgery
- Interventional Cardiology
Background:
- Carotid artery stenosis is a significant risk factor for stroke.
- Established treatments include medical therapy and carotid endarterectomy (CEA).
- Carotid angioplasty and stenting (CAS) has emerged as a newer alternative.
Purpose of the Study:
- To review and contextualize recent large-scale randomized trials comparing CAS and CEA.
- To evaluate the efficacy of CAS versus CEA in reducing stroke risk.
- To provide updated recommendations for managing carotid artery stenosis.
Main Methods:
- Review of randomized controlled trials comparing CEA and CAS.
- Analysis of data from the Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) and the International Carotid Stenting Study (ICSS).
- Synthesis of findings within the context of previous research on carotid stenosis treatments.
Main Results:
- Early CAS feasibility was established, but initial comparisons with CEA were less favorable.
- Later, larger trials (CREST, ICSS) did not demonstrate a clear neurologic outcome advantage for either CAS or CEA.
- CEA showed clear benefits for symptomatic stenosis >70% and lesser benefits for 50-69% stenosis compared to medical therapy.
Conclusions:
- Current evidence suggests comparable neurologic outcomes between CAS and CEA for most patients with carotid artery stenosis.
- Treatment decisions should consider individual patient factors and risks.
- Further research may identify specific patient subgroups who benefit more from one procedure over the other.
Abstract:
Carotid artery stenosis is a major risk factor for stroke, and treatments for this condition to decrease the risk of stroke include medical therapy, carotid endarterectomy (CEA), and, more recently, carotid angioplasty and stenting (CAS). Randomized controlled trials comparing the efficacy of CEA vs medical therapy showed a clear benefit for CEA in patients with symptomatic carotid artery stenosis of greater than 70% and a lesser benefit in patients with 50% to 69% stenosis. Treatments have evolved in the ensuing 20 years, and a new method, CAS, has emerged as a possible alternative to CEA. In early results, CAS proved feasible but did not compare favorably with CEA. Later and larger-scale studies comparing CAS to CEA failed to reach conclusions regarding a clear neurologic outcome advantage of one method over the other. This subject was of sufficient interest that 2 larger-scale randomized controlled trials comparing CAS and CEA, the Carotid Revascularization Endarterectomy vs Stenting Trial and the International Carotid Stenting Study, were undertaken to further explore this issue. This brief review places the new data arising from these studies in the context of prior efforts to address the problem of carotid artery stenosis and explores further opportunities for improvement and patient recommendations in light of these new findings.
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