Asymptomatic Patients With CAS: To Intervene or Not?

Frank J. Veith, MD


September 18, 2013

In This Article

Symptomatic Carotid Disease

Let's first talk about symptomatic carotid disease in the neck. The controversy lies between 2 invasive treatments. One is carotid endarterectomy and the other is carotid artery stenting. Again, there is a lot of controversy, much has been written, and a lot of it is influenced by bias. There are some randomized controlled trials, level 1 evidence. Some of them are good and some of them are not so good, and many of them have flaws. If one looks at these randomized controlled trials, carotid endarterectomy comes out better as a treatment than carotid stenting, in my opinion. Obviously, bias does influence that opinion a little bit, but in all of the studies, the incidence of adverse events, namely stroke, is lower with carotid endarterectomy than with carotid stenting. Even the most recent trial, CREST,[1] has been purported to show equivalence between the 2 therapies but doesn't, in my opinion, because there are more strokes and deaths after carotid stenting than after carotid endarterectomy. The number of myocardial infarctions (MI) that have occurred after carotid endarterectomy is a little higher, and that balances the stroke rate. However, a minor stroke is not equivalent to a minor MI. Minor strokes are much more serious, so I believe that even the CREST trial shows that carotid endarterectomy for symptomatic carotid disease is the superior treatment. However, carotid endarterectomy is fixed. It doesn't improve much. It is an old treatment and it is mature. Carotid stenting is constantly improving; there are better stents, better protection devices, and better techniques. My belief is that in the future, carotid stenting will approach carotid endarterectomy, but the data to date don't show that, and that is important for treating patients today.


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