Vascular intervention in stroke prevention: endarterectomy and angioplasty

Carotid stenosis is a major risk factor for stroke and transient ischaemic attack. Asymptomatic and symptomatic carotid stenoses need to be considered separately. Carotid endarterectomy was established as the treatment of choice for recently symptomatic severe carotid stenosis by two landmark trials. The effect of surgery is much less in patients with moderate carotid stenosis and harmful in patients with stenosis of less than 50%. Suitable patients should be operated on within 2 weeks of symptoms because the benefit of endarterectomy declines rapidly with increasing time between symptom onset and treatment. The benefits of endarterectomy for asymptomatic stenosis shown in the randomised trials were much less. Improvements in medical treatment, especially increasing statin use after the trials were started, need to be taken into consideration when interpreting the trials, and most neurologists conclude that routine endarterectomy for asymptomatic stenosis is not justified. Early trials of endovascular treatment of carotid stenosis suggested that endovascular treatment might be a safe and effective alternative to carotid endarterectomy. However, subsequent trials have so far failed to provide enough evidence to justify routine carotid stenting as an alternative to endarterectomy in patients fit for surgery. More data from ongoing randomised trials of stenting versus endarterectomy are needed to determine the role of stenting in the treatment of carotid stenosis.