Carotid Revascularization Strategies

Over the past decade, >1 million carotid revascularization procedures have been performed. During this time period, the frequency of carotid endarterectomy (CEA) has slightly declined, whereas carotid artery stenting (CAS) has increased.1 Somewhat surprisingly, in this timeframe, only 2 large (enrolling >1000 patients) randomized controlled trials have been initiated in North America to assess the merits of carotid revascularization approaches. Is this paucity of high-quality data due to limited funding, the influence of competing interests, or are there simply not that many burning questions left?The first of the major randomized controlled trials is the Carotid Revascularization Endarterectomy versus Stent Trial (CREST).2 The principal results of CREST, which enrolled approximately equal numbers of symptomatic and asymptomatic patients, were published in 2010. For the primary end point of periprocedure stroke, myocardial infarction, death, or subsequent ipsilateral stroke, there was not a significant difference between the 2 treatments (6.8% CEA versus 7.2% CAS, P =0.51). However, the components of the primary end point differed in the 2 groups with periprocedure stroke more common with CAS and periprocedure myocardial infarction more frequent after CEA.Where does this leave the second of …