Are symptomatic patients currently appropriate candidates for carotid artery stenting? Yes.
Most of the currently published randomized trials (RCTs) for carotid artery stenting (CAS) versus carotid endarterectomy (CEA) on symptomatic patients have concluded that CAS is associated with outcomes that are inferior to those of CEA. However, before final decision making on the future of CAS, there are some major issues of concern. Randomized controlled trials condemning CAS suffer from major study flaws, rendering comparison with CEA ineffective. These trials are challenged by methodological gaps, underpowered results, old-fashioned equipment and underuse of cerebral protection devices or even of stents. On the other hand, physicians' experience in CAS has not been that much appreciated, whereas CEA has been widely performed during the last 30 years by experienced and fully trained vascular surgeons. CAS is a recently emerged treatment that cannot yet be standardized. No matter the final verdict on CAS, the procedure will never be for low volume practitioners. It is required that CAS be performed exclusively in high volume centers with specific dedicated experience and adequate training. Yet, optimistic results on CAS have been constantly reported from single, highly specialized CAS centers around the world. Regarding restenosis rates, they should be evaluated on the true need for re-intervention, since its clinical significance is still debated; but even when decision is undertaken to operate a restenosis, a repeat endovascular procedure is safe with reported complication rates < 1%. Concluding, vascular surgeons should be thoughtful about rejecting it as an alternative to CEA, because with advancing technology, vascular surgeons electing to stay away, and not perform CAS, will stay out of the "race."
Avgerinos
Efthimios D
ED
Department of Vascular Surgery, Attikon University Hospital, Athens, Greece. efavgerinos@gmail.com
Brountzos
Elias N
EN
Dalainas
Ilias
I
Liapis
Christos D
CD
D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation*; D016893:Carotid Stenosis / Q000150:complications / Q000601:surgery / Q000628:therapy*; D002983:Clinical Competence; D016894:Endarterectomy, Carotid / Q000009:adverse effects; D019317:Evidence-Based Medicine; D006801:Humans; D018579:Patient Selection; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D016896:Treatment Outcome