Endarterectomy vs. stenting vs. medical therapy

In recent trials, after deducting the risks in the 30-day periprocedural period, the long-term risk of stroke or death was similar with carotid stenting (CAS) and endarterectomy (CEA) for asymptomatic carotid stenosis (ACS) - approximately 0.5% per year. These findings may exacerbate the problem of inappropriate routine intervention in ACS, being justified on the basis of an invalid comparison of the risks in the medical arms of clinical trials conducted decades ago (˜ 2% per year) to the risks in modern trials of CAS vs. CEA with no medical arm. Intervention is regarded as justified if it can be carried out with a risk below 3%. The annual risk of ipsilateral stroke or death in ACS with intensive medical therapy is now ˜ 0.5% - similar to the long-term risk after the periprocedural period in recent trials of intervention. However, periprocedural risk was ˜ 3% for CAS and 1.7% for CEA. Thus with modern CAS and CEA, the risk remains much higher than with modern medical therapy, even with careful vetting of the surgeons and interventionalists. In real world practice, documented in registries, the risks are much higher. National differences - 90% of carotid intervention for ACS in the US vs. 0% in Denmark - bring into question the advisability and ethics of routine intervention. A moratorium on routine intervention for ACS should be respected except in ongoing randomized trials comparing CAS, CEA and modern intensive medical therapy. Patients with high-risk ACS can be identified for appropriate intervention.