title: Future management of carotid stenosis: role of urgent carotid interventions in the acutely symptomatic carotid patient and best medical therapy for asymptomatic carotid disease.
abstract: BACKGROUND
  Stroke is the fourth leading cause of death in the United States, leading to devastating disability. Most strokes are ischemic, and nearly one-third of these are caused by carotid disease. The primary mechanism of carotid-related stroke is an atheroembolic event from an unstable atherosclerotic plaque rupture. In the 1990s, randomized trials demonstrated the benefit of carotid endarterectomy (CEA) in reducing the risk of stroke in both symptomatic and asymptomatic carotid disease.
  
  
  METHODS
  We review best medical therapy (BMT) for asymptomatic carotid disease and recent randomized trials comparing CEA and carotid angioplasty stenting (CAS), and we discuss the role of urgent carotid interventions in patients with acute neurologic symptoms.
  
  
  RESULTS
  In 2010, 2 large trials demonstrated the efficacy of CAS in select patients, although CAS was associated with an increased procedural stroke risk compared to CEA. An age effect was observed; patients >75 years do worse with CAS compared to CEA. As BMT has evolved in the past decade, a future trial (CREST-2) will address whether BMT is equal to intervention (CEA or CAS) in asymptomatic carotid disease. In a subgroup of patients with asymptomatic carotid disease, CEA plus BMT will likely remain the mainstay therapy for carotid disease compared to BMT alone. CEA and CAS will continue to play complementary roles in the future, as CAS will be done in select patients in whom CEA cannot be undertaken because of high-risk anatomical or medical conditions. Finally, a role for urgent carotid interventions in a select group of patients who present with acute neurologic symptoms is developing as a way to prevent recurrent stroke after an initial carotid plaque rupture event.
  
  
  CONCLUSIONS
  CAS has an increasingly higher risk of stroke with advancing age. Patients treated with CAS have a 1.76-fold increased risk of stroke (95% CI, 1.35-2.31) with each 10-year increase in age. No such age effect is seen in patients treated with CEA. Age is a critical variable in making informed choices regarding treatment of severe carotid artery stenosis.
authors.affiliation: Section of Vascular and Endovascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA ; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.
authors.forename: Hernan A
authors.initials: HA
authors.lastname: Bazan
authors.affiliation: Section of Vascular and Endovascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA ; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.
authors.forename: Taylor A
authors.initials: TA
authors.lastname: Smith
authors.affiliation: Section of Vascular and Endovascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA.
authors.forename: Melissa J
authors.initials: MJ
authors.lastname: Donovan
authors.affiliation: Section of Vascular and Endovascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA ; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.
authors.forename: W Charles
authors.initials: WC
authors.lastname: Sternbergh
keywords: Carotid angioplasty stenting; carotid disease; carotid endarterectomy; carotid stenosis