Carotid artery stenosis: endarterectomy or stenting?

Stenosis of the internal carotid artery may be responsible for 10%–20% of all strokes or transient ischemic attacks. Stroke is the third leading cause of death and the most common cause of permanent disability in western countries. Until the introduction of carotid artery stenting (CAS), carotid endarterectomy (CEA) was the only surgical solution to the potential embolic and thrombotic load of the carotid plaque. Over the past few years, medical therapy has made enormous progress because of the introduction of new drugs and the widespread and more effective control of vascular risk factors. The choice of treatment between CEA, CAS, or medical therapy alone for any individual patient with carotid stenosis remains a controversial issue. However, a simple complete method to independently stratify the peri-interventional neurologic outcomes of patients undergoing CAS is still lacking. CEA has been used to treat carotid disease for greater than 50 years. Over this period, CEA was validated by large multicenter randomized clinical trials as an effective method for stroke prevention. Indication for CEA with defined outcomes has markedly improved and technical aspects have evolved but an ideal surgical technique has yet to be determined. Consequently, as a practical matter, most vascular surgeons use a number of technical variations for CEA in their clinical practice and adapt their preference to each particular situation. About carotid artery stenting (CAS), in the last years evolution in both stents and protection devices as well as in carotid stenting techniques, resulted in an important reduction in stroke rate in patients undergoing CAS procedure. But carotid stenting, although a mature technique regularly applied with excellent outcomes in high-volume centers by expert operators, is struggling to find the consensus of the scientific community. A key issue in limiting periprocedural events to the lowest possible is to select the appropriate device for the appropriate patient anatomy and clinical syndrome. An important element of this concept is the recognition of high-risk cases for CAS dependent primarily on the skill of the interventional vascular specialist, a factor that is substantially more relevant in the field of CAS than other areas of percutaneous intervention. Evaluation of different types of interventions, medical therapy, carotid endarterectomy (CEA) or CAS and their continuous evolutions, a tailored approach to the patient is considered now the best treatment in carotid artery stenosis.