Abstract

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 ECST and NASCET trials in symptomatic patients followed by ACAS and ACST in asymptomatic patients.^2-5 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 following 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 RCTs⁸ 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 regarding 30-day ‘death’ and ‘death/disabling stroke’, nor the risk of late stroke.⁷