[What future for carotid stenosis management?]

Surgery remains the first choice intervention in patients with severe symptomatic carotid stenosis. Stenting is associated with a higher periprocedural risk of stroke compared with surgery. This excess risk of stroke with stenting mainly concerns patients older than 70years, whereas the risk seems to be similar in patients younger than 70years. After the procedural period, both surgery and stenting appear to be as effective to prevent stroke. Studies are ongoing to identify patients who benefit most from carotid surgery or stenting. In patients with asymptomatic carotid stenosis, the risk of first ipsilateral stroke on medical treatment alone is currently lower (less than 1% per year) than it was at the time of randomized clinical trials, which showed a modest benefit of carotid surgery over medical treatment alone. Randomized trials are ongoing to re-assess the benefit of carotid revascularization in patients with asymptomatic carotid stenosis. Pending results of these trials, carotid revascularization should remain a case by case decision, taking into account the individual risk of ispilateral stroke, the risk of revascularization, the predicted life expectancy, and patient's preferences.