In Patients with Symptomatic Carotid Artery Stenosis Is Endarterectomy Safer Than Carotid Stenting?

Abstract

Stroke is a leading cause of morbidity, mortality, and health care expenditure in the United States. Carotid disease accounts for a significant number of ischemic strokes and debate continues as to the most appropriate management for symptomatic carotid stenosis. The importance of surgical intervention, i.e. carotid endarterectomy (CEA), for symptomatic carotid stenosis has been widely accepted based on multiple well-constructed trials published in the early 1990s. Carotid artery stenting (CAS) was initially approved by the FDA in 2004, and has gained momentum as an alternative to CEA. A number of multicenter trials have demonstrated the safety of CAS in both asymptomatic and symptomatic patients; however questions remain as to the long-term durability, as well as the proper patient selection for CAS. In this chapter, we review the current methods of treatment of symptomatic carotid stenosis, and discuss factors that influence the decision to perform CEA or CAS. In general, if the surgeons risk of stroke is acceptably low, CEA should be performed for patients with a >50 % symptomatic carotid stenosis. CAS should only be considered as an alternative for those with prohibitive medical comorbidities, and those with hostile anatomy.