Endarterectomy vs. stenting vs. medical therapy

Area of Science:

• Vascular Surgery
• Neurology
• Interventional Cardiology

Background:

• Asymptomatic carotid stenosis (ACS) management is controversial.
• Previous comparisons of intervention vs. medical therapy used outdated data.
• Modern medical therapy offers significant risk reduction.

Purpose of the Study:

• To evaluate the long-term risks of carotid stenting (CAS) and carotid endarterectomy (CEA) versus medical therapy for ACS.
• To address the issue of potentially inappropriate routine interventions.

Main Methods:

• Analysis of recent clinical trial data comparing CAS and CEA.
• Comparison of periprocedural and long-term risks.
• Evaluation of risks associated with modern intensive medical therapy.

Main Results:

• Long-term stroke or death risk after CAS and CEA is similar to medical therapy (~0.5% annually) after the periprocedural period.
• Periprocedural risks for CAS (~3%) and CEA (~1.7%) are higher than the annual risk of medical therapy.
• Real-world registry data indicate even higher risks for interventions.

Conclusions:

• Routine intervention for ACS is often not justified due to periprocedural risks exceeding benefits compared to modern medical therapy.
• A moratorium on routine ACS intervention is suggested, except for ongoing trials.
• Identification of high-risk ACS patients for appropriate intervention is crucial.