Carotid Endarterectomy

Stenting (see Plate 9-17) has been investigated as an alternative therapy for patients with carotid artery disease. Two multicenter studies, the International Carotid Stenting Study (ICSS) and the North American Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), have compared the efficacy of carotid endarterectomy versus carotid stents in patients with symptomatic and asymptomatic carotid artery disease and showed somewhat different results.

The ICSS was the first randomized trial for symptomatic patients with at least 50% internal carotid stenosis. This study showed that the risk of stroke, death, and myocardial infarction (MI) in the carotid artery stenting group was significantly higher than in the surgical arm (8.5% versus 5.2%, P = .006) with a major difference in the occurrence of minor strokes. This finding was also supported by the results of a MRI substudy showing more diffusion-weighted imaging lesions in patients submitted to a carotid stent than to a CEA.

The CREST enrolled symptomatic patients with at least 50% stenosis on angiography or 70% by ultrasound as well as asymptomatic ones with at least 60% stenosis by angiography or 70% stenosis by ultrasound. This trial showed no difference between the risks of stroke, death, and MI in patient treated with a stent or CEA; however, periprocedural strokes and death in symptomatic patients were significantly higher in patients treated with stents (6%) versus CEA (3.2%, P = .02), whereas MI was more frequent in patients treated with CEA.

Stricter practitioner credentialing requirements and inclusion of lower-risk asymptomatic patients in the CREST probably explain some of the different results between these two trials. Until further studies are done, carotid endarterectomy is still the treatment of choice for patients with symptomatic carotid artery disease.

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