Carotid Artery Stenting and Endarterectomy: a clinical evaluation

Stroke is a major cause of mortality and morbidity in the western world. Atherosclerotic disease of the carotid arteries is in approximately 25% of the cases responsible for the cerebral infarction.1 Since NASCET and ECST, carotid endarterectomy (CEA) is considered the standard treatment for severe atherosclerotic carotid obstructive disease in symptomatic patients.2, 3 Similar landmark studies were performed for asymptomatic carotid artery disease.4, 5 On the basis of these trials the American Heart Association has recommended CEA for symptomatic patients with stenosis of 50% to 99% if the perioperative risk of stroke or death is <6%.6 In asymptomatic patients CEA is recommended for a stenosis of 60% to 99% if the perioperative of stroke or death is < 3%. In an effort to minimise interventions, in the last decade carotid artery stenting (CAS) has been suggested as an alternative to surgical endarterectomy for patients with symptomatic and asymptomatic extra cranial obstructive disease. Initially, percutaneous transluminal balloon angioplasty (PTA) was used. Later stent placement was introduced and has been used with or without initial PTA. Current data on CAS and CEA suggest that CAS is quickly gaining ground on CEA as a first-line treatment The advantages of CAS include avoidance of general anaesthesia, an incision in the neck and the risk of cranial and cutaneous nerve damage from the dissection. Surgically inaccessible lesion can be treated with CAS and both procedure- and admission times are usually shorter than for surgery, therefore reducing some cost. On the other hand, devices used for CAS are more expensive. At this moment many interventionists embrace carotid stenting, in particular for patients with obvious contraindications for surgical endarterectomy like high cardiopulmonary risk, high cervical lesion or “hostile neck”. CAS is relatively new compared to CEA and it should be acknowledged that CAS is an evolving technique and dedicated materials became only available recently.

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