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Carotid revascularization with carotid endarterectomy (CEA) has been shown to be superior to medical therapy for stroke prevention in symptomatic and asymptomatic patients with moderate to severe stenosis who meet well defined medical and surgical selection criteria. The benefit of CEA is significantly higher in symptomatic compared to asymptomatic patients. Carotid artery stenting (CAS) has emerged as an alternative in patients who are considered high surgical-risk due to co-existent medical co-morbidities or anatomical high-risk features. Since its development in the early 1990’s, the technique of endovascular carotid revascularization has been undergoing a continuous maturation process mainly due to a change from the initial use of balloon expandable stents to self-expanding stents, the introduction of and continuously improving array of emboli prevention devices (EPD's) and last but not least increasing operator experience. This culminated in the randomized SAPPHIRE trial of protected CAS [i.e., CAS performed with EPD] vs. CEA in high surgical-risk patients, that showed that CAS was non-inferior to CEA with lower peri-procedural complication rates as well as lower rates of restenosis (Yadav et al., 2004). Furthermore, increased experience with this technique has led to the realization that just like with CEA, there are patients (e.g., older age, excessive vascular tortuosity or calcification) who are high-risk for CAS. (Chaturvedi et al., 2010).

Carotid Endarterectomy vs. Carotid Stenting: Fairly Comparable or Unfairly Compared?