Carotid stenosis: endarterectomy or angioplasty and stenting?

Atherosclerotic narrowing of the proximal internal carotid artery is an important mechanism in ischemic stroke. Optimal medical management of internal carotid stenosis includes antiplatelet agent and statin administration, blood pressure reduction, weight control, and smoking cessation. Decisions regarding the use of invasive procedures to treat carotid disease--specifically carotid endarterectomy and carotid angioplasty and stenting--must weigh the long-term risk reduction in ipsilateral ischemic stroke against the immediate intervention risks. Clinical trials evaluating the benefits of carotid endarterectomy were conducted before widespread use of statins and newer blood pressure-lowering agents such as angiotensin-receptor blockers; it is unclear what impact this may have had on trial results. Regardless, carotid endarterectomy is clearly superior to medical therapy for patients with symptomatic severe stenosis. Conversely, the benefit from endarterectomy is muted in individuals with symptomatic moderate stenosis or asymptomatic stenosis, and decisions regarding surgical intervention must incorporate surgeon proficiency and patient comorbidity. Currently, there is a lack of evidence to support the use of carotid artery angioplasty and stenting in the routine management of carotid disease. Selected patients with severe symptomatic stenosis for whom endarterectomy cannot be safely performed may still benefit from endovascular management. However, it is unlikely that asymptomatic patients or symptomatic patients with moderate stenosis considered at high risk for endarterectomy would benefit from any intervention.