Purpose of review: To summarize randomized controlled trials on endarterectomy and stenting of symptomatic carotid stenoses and identify factors that impact the decision for either therapeutic method.
Recent findings: Carotid endarterectomy is currently the standard method of secondary stroke prevention in patients with moderate-to-severe symptomatic carotid artery stenosis. Carotid artery stenting has emerged as a therapeutic alternative. The noninferiority to endarterectomy with respect to periprocedural safety has not been proven, but the long-term efficiency of stroke prevention after successful stenting is very similar, despite the observation that the rate of restenosis after stenting is significantly higher than after endarterectomy. Thus, the key difference between stenting and surgery is periprocedural safety. From subgroup analysis of the Stent-protected Percutaneous Angioplasty versus Endarterectomy data, it emerges that elderly patients are at higher than average periprocedural risk of ipsilateral stroke on the day of stenting but not if treated by surgery. This finding is an argument for catheter access problems through tortuous vessels with severe atherosclerosis in the proximal carotid artery of elderly patients as the source of periprocedural risk of stenting.
Summary: Carotid artery stenting for secondary stroke prevention is a method with unproven noninferiority of periprocedural safety but similar long-term efficiency compared to endarterectomy.