Carotid stenting versus carotid endarterectomy: update on the controversy

Carotid stenting has been a controversial subject from the outset. This discussion examines three areas: What is the basis for clinical investigation of carotid stenting? How do the results seem to compare with current surgical practice? Are there important things we do not know about carotid stenting? Does carotid stenting produce equal or better stroke prevention over a significant period than conventional therapy? Is the short-term morbidity, both neurological and general, better than with carotid endarterectomy? Does carotid stenting reduce cost? The results of recent series of carotid endarterectomy, some from National Institutes of Health (NIH)-funded randomized studies with peer-reviewed data, others from large referral centers or large regional experiences, and the results of several single-institution case series of carotid stenting that are reported in complete manuscript form are summarized. At least four industry-sponsored trials of carotid stent technology use are being undertaken in the United States as of the fall of 1997. Considering that angioplasty and stenting in other vessels has been used in many thousands of patients for over a decade, it is surprising that some basic issues are not resolved more clearly than they seem to be. Specifically in relation to the carotid lesion, seven questions are posed that frame some controversial aspects of the role of carotid stenting in stroke prevention.