ICSS and EXACT/CAPTURE: More questions than answers.

The International Carotid Stenting Study (ICSS) and an amalgamated 'super' Registry of 'high risk for surgery' patients undergoing carotid artery stenting (CAS) have issued seemingly contradictory conclusions following release of their 30-day procedural risks. This paper evaluates the impact of the two trials, regarding the current status of CAS, and concludes that there are still more questions than answers. The available evidence supports CAS in the treatment of selected 'high risk for CEA' non-octogenarian symptomatic patients, provided certain caveats are met (maintenance of acceptable procedural risk, rapid intervention). There is, however, no level I evidence supporting the routine use of CAS in 'standard risk' symptomatic patients and this Cochrane recommendation will not change once the ICSS data are included. It is anticipated, however, that following meta-analyses of individual patient data from 5000 patients recruited into the four large, randomised trials (SPACE, EVA-3S, ICSS, CREST), selected patient subgroups will be identified who will benefit by being treated by CAS. In the meantime, the majority of standard risk, symptomatic patients should probably undergo expedited CEA. However, established (or less experienced) practitioners who intend to continue offering CAS to this category of patient (because it is already approved practice in their health system) must ensure that their audited 30-day risks of death/stroke remain <6% and that they offer patients access to expedited intervention (ie within 2 weeks) wherever possible. Delaying intervention in order to reduce the procedural risk may improve the reputation of the surgeon/interventionist, but it confers little overall benefit to the patient.