Dr. Safi:

Carotid endarterectomy is a time-tested, effective, durable and safe procedure that has been used in clinical practice since its introduction, in Houston, by Dr. DeBakey in 1953.  Current case volumes are in the range of 140,000 per year in the USA.  Combined perioperative death and stroke risk is 2-5% in the community, and is substantially better – around 1% in high-volume centers.  Endarterectomy has been subjected to rigorous testing in large randomized trials, and has been shown reliably to be superior to medical management, with a number needed to treat of 6 for symptomatic patients in the NASCET trial.  Results of carotid stent trials have been mixed, with some showing benefit and some showing harm.  Until a treatment superior to endarterectomy is not only developed but proven, the surgical approach should be the standard of care.

Dr. McPherson:

Significant progress has been made in the design and deployment of carotid arterial stents since the first-generation devices were introduced a decade ago, most importantly in the area of distal protection device development.  Although early trial results were mixed, a recent large randomized trial (SAPPHIRE) using contemporary technology has shown noninferior or even favorable results of stenting compared to endarterectomy for symptomatic patients.  Currently, the CREST trial is evaluating stents in patients with and without symptoms, and should produce additional level one evidence soon.  Carotid stenting is particularly attractive in cases where patients have hostile necks or other difficult anatomy.  Catheter-based technologies are constantly improving and are here to stay.