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Introduced in the 1950s, carotid endarterectomy (CEA) proliferated in the 1970s, only to become the subject of criticism in the 1980s when its appropriateness was questioned.1 Primacy was restored with the European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) in symptomatic patients followed by the Asymptomatic Carotid Atherosclerosis Study (ACAS) and the Asymptomatic Carotid Surgery Trial (ACST) in asymptomatic patients.2 3 4 5 However, this proved to be only a temporary respite because by the late 1990s, CEA was once again the subject of scrutiny following the emergence of carotid artery stenting (CAS) as a viable and less invasive alternative.6 However, despite initial optimism after Brown’s 1992 systematic review (30-day death/stroke rate after unprotected angioplasty without stenting was <1% in 123 pooled patients6), no fewer than 12 randomised controlled trials (RCTs)7 have subsequently failed to resolve the debate. The 2007 Cochrane review concluded that CAS conferred significant reductions in cranial nerve injury (a very important observation), but that it was associated with a significant increase in the 30-day risk of “death/any stroke” and “any stroke”. There was no difference for 30-day “death” and “death/disabling stroke”, or for the risk of late stroke.8
Why then have RCTs not resolved this debate? The explanation is multifactorial but important to remember as different interpretations of the literature are presented to the reader. First, many interventionists feel that the early RCTs8 9 10 used obsolete CAS technology (by current standards) and these should be excluded from any contemporary systematic review. While understandable, this has tended to become a repetitive response and was even cited in 2006 debates on the Stent Protected Angioplasty versus Carotid Endarterectomy (SPACE) trial and Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial.11 …
Competing interests None.
Provenance and Peer review Not commissioned; not externally peer reviewed.
Addendum The ICSS trial reported its 30-day findings on 28 May 2009, concluding that CEA was statistically superior to CAS. The trial recruited 1700 recently symptomatic patients from 50 centres in 15 countries and on an “intention-to-treat” analysis, the 30-day risk of death/stroke was 5.1% after CEA compared with 8.5% after CAS (p = 0.004). On a “per protocol” analysis, the respective figures were 4.0% after CEA versus 7.4% after CAS (p = 0.003). These results do not mean that CAS should be abandoned, but there is clearly uncertainty about its optimal role. It is expected that the data from ICSS, EVA-3S and SPACE will be combined in order to identify subgroups (possibly younger patients) in whom CAS is preferable.