Carotid Angioplasty and Stenting: State-of-the-Art After CREST Study

Abstract

Stroke represents the third leading cause of death in the USA and the most common and disabling neurological disorder in the elderly population. A carotid stenosis is responsible for about 30% of the cases. Medical therapy with antithrombotic agents and statins has a role in reducing cardiovascular risk, but randomized trials have shown that carotid endarterectomy (CEA) is superior to medical therapy alone and is considered the gold standard treatment of a carotid stenosis. However, surgery is not without complications; the stroke and death rate at 30 days in these trials ranged from 5.8% to 7.5% in the symptomatic patients and from 2.3% to 4.3% in asymptomatic patients. In higher risk patients, like those with severe coronary artery disease, morbidity and mortality has been reported in up to 18% of patients. Carotid angioplasty and stenting (CAS) has been proposed as an alternative to surgery, and two initial randomized studies comparing CAS and CEA showed comparable results. However, after these results, numerous studies, both European and American studies, have been published with very different outcomes. Among them the most important is the American study, CREST, which demonstrated that CAS is not inferior to CEA and can now be proposed to the majority of patients suffering from a carotid stenosis. But in contrast to many other endovascular interventions, CAS represents a more challenging procedure requiring complex catheter-based skills and an extensive learning curve that explains the poor results of CAS in some published series and particularly in Europeans studies.
In conclusion, after the CREST study and recent published data, CAS and CEA can be deemed equivalent for the treatment of a carotid stenosis. However, these two treatments may have some contraindications and limitations. We need appropriate patient and lesion selection, proper technique, embolic protection devices, and most importantly experienced operators. Indications for asymptomatic patients have to be discussed considering the benefit of optimal medical therapy.