Carotid artery stenting in asymptomatic and surgically high-risk patients: Single-centre, single-operator results

Stroke represents the third leading cause of death in developed countries and the leading cause of disability in the elderly (1). Eighty per cent of strokes are ischemic, with the extracranial carotid artery contributing to 20% to 30% of cases. Among those patients, nearly one-half were previously asymptomatic (2,3). Surgical carotid endarterectomy (CEA) has been performed effectively for over 50 years as the primary treatment strategy for both symptomatic and asymptomatic patients with carotid artery disease. Substantial long-term hemodynamic and clinical benefits are attributable to this operation (4). However, several studies have shown that the clinical ‘real-world’ practice of carotid artery therapy involves many patients who would have been excluded from the major CEA studies and are at a high operative risk. Thus, there is still an ongoing debate on stroke prevention in surgically high-risk asymptomatic patients. The present discussion proceeds from the assumption that in the medical arms of the Asymptomatic Carotid Atherosclerosis Study (ACAS) and the Asymptomatic Carotid Surgery Trial (ACST), five-year rates of death or stroke were similar (12%) (5). Therefore, periprocedural rates of death or stroke in asymptomatic patients must not exceed 3% (2). However, an overview of published registries and observational studies demonstrated rates of death or stroke at 30 days of 0.8% to 3.8% in asymptomatic patients (6–8). We retrospectively analyzed a single-centre, single-operator registry to evaluate feasibility and safety of carotid artery stenting (CAS) with distal protection devices in consecutive, asymptomatic, surgically high-risk patients who were scheduled for endovascular treatment of significant carotid stenoses. The purpose of the present study was to answer the question of whether endovascular therapy is appropriate in this group of patients.