Extracranial Carotid Disease Revascularization

Extracranial carotid artery stenosis is a factor in ≈20% to 30% of all strokes.1,2 Revascularization strategies using surgical carotid endarterectomy (CEA) or carotid artery stenting (CAS) offer the possibility of stroke prevention by restoring flow and mitigating the risk for future plaque-associated embolization. Numerous studies have assessed whether these procedures reduce the risk for stroke and improve overall clinical outcome, but many issues and questions remain. The available clinical outcome data have highlighted the differential risk and benefit among symptomatic versus asymptomatic patients, the impact of older age and sex, and the surgical risk for CEA related to either anatomic or medical factors. Likewise, the important issues of operator training and experience and refinement of technique for both CEA and CAS affect the interpretation of clinical trial results and the generalization of these results to broader populations of patients and operators. To what extent other cardiovascular outcomes such as myocardial infarction (MI) and cardiac death should be incorporated into the interpretation of specific clinical trials for stroke prevention is also an important consideration. Finally, the lack of data for comparing contemporary medical therapy with revascularization for reduction of stroke and overall cardiovascular outcomes is a serious shortfall. This review assesses the results of historical and more recent clinical trials of the comparative effectiveness of carotid revascularization in the context of these clinical issues.Comparisons between MI and stroke secondary to extracranial carotid artery stenosis are often drawn. Although symptomatic carotid plaques share similarities with vulnerable coronary plaques such as thinned fibrous caps, ulceration, and large necrotic lipid cores,3 acute coronary events are related mainly to plaque rupture with secondary thrombosis and may occur frequently in association with only mild or moderate coronary stenosis.4 The resultant complete or partial occlusion of the coronary artery leads to …