Latest Skirmishes in the Long-Term Battle Between Carotid Endarterectomy and Stenting

The first descriptions of carotid angioplasty appeared more than 30 years ago, but it is only now that we have good evidence to support endovascular treatment of carotid disease. Endovascular treatments were originally proposed as less invasive than carotid endarterectomy. This concept was challenged by those who argued that endovascular procedures were likely to dislodge clot or atheromatous debris into the brain. There was also concern that endovascular treatments did not remove the underlying pathology and would have a high incidence of recurrent symptoms. In part, this led to the development of stents designed to hold the artery open and prevent plaque rupture. However, laboratory studies suggested that the lengthening of stents during deployment sheared off atheromatous debris into the distal vessel. It was only after the introduction of protection devices, such as filters placed distal to the stenosis, that carotid stenting became regarded as suitable for mainstream use. This concept was sufficiently promising for several large randomized trials to begin to compare stenting with endarterectomy.Debate about the periprocedural risks has distracted attention from the main aim of carotid revascularization, the long-term prevention of ipsilateral stroke. The majority of stented patients, around 95%, survive the procedure without major complications. Thus, the important question for these patients is whether stenting is durable in terms of preventing stroke. The publication of long-term results from the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) provides reassuring data that addresses this question.1 CREST included 1607 patients with carotid stenosis who consented to long-term follow-up. The rate of postprocedural stroke over a median follow-up of 7.4 years was 6.9% in the stenting group and 5.6% in the endarterectomy group (hazard ratio [HR], 0.99; 95% confidence …