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In western countries, stroke is the third most frequent cause of death, behind cardiac disease and cancer, and is the number one condition associated with permanent disability. Large artery atherosclerosis—mostly located at the carotid bifurcation—may account for up to 20% of all ischaemic strokes. Atherosclerosis is by far the most common pathology causing carotid artery stenosis and typically affects the origin of the internal carotid artery. The pathophysiology of stroke in patients with carotid artery stenosis is commonly distal embolisation of plaque material into the intracranial vasculature, while in the presence of a critical stenosis, hypoperfusion may also play a role. The most important predictor of stroke in patients with carotid artery stenosis is the presence of symptoms—amaurosis fugax, transient ischaemic attack (TIA) or stroke—followed by the severity of stenosis. In the North American Symptomatic Carotid Endarterectomy Trial (NASCET), the risk of stroke for patients with symptomatic carotid artery stenosis treated medically was 26% over 2 years (13%/year) for >70% stenosis and 18.5% over 5 years (4.4%/year) for 50–69% stenosis.w1 In asymptomatic patients with carotid artery stenosis >60%, the yearly risk of stroke is 1–2% per year.w2 However, the risk may increase to 3–4% per year in elderly patients or in the presence of a severe stenosis, contralateral carotid stenosis or occlusion, carotid plaque heterogeneity, poor collateral blood supply, generalised inflammatory states, and cardiac or medical illnesses.
Large scale randomised trials have established the superiority of carotid endarterectomy (CEA) over medical management for stroke prevention in patients with symptomatic—and to a lesser degree asymptomatic—internal carotid artery stenosis. In the last decade, carotid artery stenting (CAS) has been advocated as a less invasive alternative to surgery. Recently, the value of carotid revascularisation in asymptomatic patients has been questioned because patients allocated to the conservative arms of the trials were not treated …