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Carotid Endarterectomy still the "gold standard" for revascularization in symptomatic patients.

Susan C. Fagan, Pharm.D., BCPS, FCCP
December, 2006

Study: Mas J-L, Chatellier G, Beyssen B, et al. Endarterectomy versus Stenting in Patients with Severe Carotid Stenosis. N Engl J Med 2006;355:1660-1671.

Editorial: Furlan AJ. Carotid artery stenting - case open or closed? N Engl J Med 2006;355:1726-1729.

Carotid endarterectomy is a highly effective surgical procedure for reducing the risk of recurrent thromboembolic events in patients with symptomatic (ischemic symptoms emanating from brain on the side of the stenosis) carotid artery stenosis of 60-99%. It carries with it, however, a significant risk of perioperative stroke and death (up to 6% is acceptable to make the procedure still worth the risk in symptomatic patients). In addition, the cranial nerve injury due to the invasive procedure can be irreversible. There has been a move to develop less invasive, endovascular procedures (stenting) to decrease the morbidity of the procedure. In the previously published SAPPHIRE trial, stenting was as effective as endarterectomy but appeared to be safer in a primarily asymptomatic population, where the perioperative risk is lower.1 In this trial, EVA-3S, despite the use of protective devices to prevent perioperative embolization (92% of patients) and dual antiplatelet therapy for 3 days before and 30 days after (82%) in most patients, the study was stopped early for safety and futility. In the stented group, the 30 day incidence of stroke or death was 9.6%, compared to 3.9% with endarterectomy. This was highly significant. Most of the events in the stented group occurred on the day of the procedure.

It is clear that the gold standard for revascularization of symptomatic carotid stenosis remains carotid endarterectomy. Only in patients where surgery is not an option should stenting be considered.

1. Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2006;355:1660-1671.

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