Carotid stenting and angioplasty: A statement for healthcare professionals from the councils on cardiovascular radiology, stroke, cardio-thoracic and vascular surgery, epidemiology and prevention, and clinical cardiology, american heart association

Carotid artery stenosis, particularly involving the origin of the internal carotid artery, is a frequent clinical problem. These stenoses, almost invariably atherosclerotic, can present as asymptomatic bruits discovered on physical examination, one or more transient ischemic attacks related to embolization of thrombus from stenotic lesions or to hypoperfusion, or less commonly, as an ischemic stroke. From the results of three high-quality prospective randomized trials,1 2 3 it has become apparent that symptomatic stenoses that narrow the diameter of the carotid artery more than 60% to 70% lead to a significant incidence of stroke if treated medically. The risk of stroke associated with such a lesion in symptomatic patients treated with antiplatelet therapy alone is thought to be 26%.3 With carotid endarterectomy and aspirin, this risk is lowered to 9%, a statistically significant difference.3 In patients with or without symptoms who have a stenosis ≤60%, the effectiveness of either medical therapy or carotid endarterectomy in preventing significant neurological events is not known. In symptomatic patients with <30% stenosis, medical therapy is superior to surgical therapy.2 Studies attempting to define the benefit of therapy in symptomatic patients with <60% stenosis are currently under way. Accrual of patients has slowed, however, because data show clear efficacy in symptomatic patients with stenoses ≥70%, leading to a bias toward surgery in symptomatic patients with less severe stenoses. In general the role of surgery for asymptomatic stenosis remains controversial, with some recent opinions suggesting that it may not be indicated.4 In one high-quality trial with selected experienced surgeons, there was a modest reduction in absolute risk in asymptomatic patients with stenosis ≥60%, but the significance of this finding has been debated.5 6 Although mortality associated with conventional antiplatelet therapy has been minimal,7 surgery clearly has significant perioperative morbidity and …