Review Endarterectomy or carotid artery stenting: the quest continues Michiel G. van der Vaart, M.D. a , Robbert Meerwaldt, M.D., Ph.D. b , Michel M.P.J. Reijnen, M.D., Ph.D. c , René A. Tio, M.D., Ph.D. d , Clark J. Zeebregts, M.D., Ph.D. a, * a Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, 9700 RB Groningen, The Netherlands b Department of Surgery, Isala Clinics, Zwolle, The Netherlands c Department of Surgery, Alysis Zorggroep, Lokatie Rijnstate, Arnhem, The Netherlands d Department of Cardiology, University Medical Center Groningen, 9700 RB Groningen, The Netherlands Manuscript received May 24, 2007; revised manuscript July 3, 2007 Abstract Background: Carotid endarterectomy (CEA) is still considered the “gold-standard” of the treatment of patients with significant carotid stenosis and has proven its value during past decades. However, endo- vascular techniques have recently been evolving. Carotid artery stenting (CAS) is challenging CEA for the best treatment in patients with carotid stenosis. This review presents the development of CAS according to early reports, results of recent randomized trials, and future perspectives regarding CAS. Methods: A literature search using the PubMed and Cochrane databases identified articles focusing on the key issues of CEA and CAS. Results: Early nonrandomized reports of CAS showed variable results, and the Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy trial led to United States Food and Drug Administration approval of CAS for the treatment of patients with symptomatic carotid stenosis. In contrast, recent trials, such as the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial and the Endarterectomy Versus Stenting in Patients with Symptomatic Severe Carotid Stenosis trial, (re)fuelled the debate between CAS and CEA. In the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial, the complication rate of ipsilateral stroke or death at 30 days was 6.8% for CAS versus 6.3% for CEA and showed that CAS failed the noninferiority test. Analysis of the Endarterectomy Versus Stenting in Patients With Symptomatic Severe Carotid Stenosis trial showed a significant higher risk for death or any stroke at 30 days for endovascular treatment (9.6%) compared with CEA (3.9%). Other aspects–such as evolving best medical treatment, timely intervention, interventionalists’ experience, and analysis of plaque compo- sition–may have important influences on the future treatment of patients with carotid artery stenosis. Conclusions: CAS performed with or without embolic-protection devices can be an effective treatment for patients with carotid artery stenosis. However, presently there is no evidence that CAS provides better results in the prevention of stroke compared with CEA. © 2008 Excerpta Medica Inc. All rights reserved. Keywords: Carotid endarterectomy; Embolic-protection device; Stenting; Stroke prevention Stroke and stroke-related death are increasing causes of concern in the western world. Currently, stroke is the third most common cause of mortality [1,2]. A Swedish publica- tion showed for the first time a stroke incidence of 213/ 100,000 persons annually [3]. This generates an enormous financial burden to the western society, as shown by a German cost analysis [4]. Direct medical costs for a first- event, first-year survivor are €18,517 (USD $25,016)/ patient, and lifetime costs are €43.129 (USD $58,257)/ patient. This in turn accounts for 3% to 4% of total health care costs in several European countries [4]. The estimated direct and indirect cost generated so far by stroke in 2007 in the United States is USD $62.7 billion [2]. Extracranial cerebral atherosclerosis causes 8% to 29% of all ischemic strokes [5]. Thrombotic emboli arising from cardiac origin are another more frequent cause of ischemic strokes [6–8]. The aim of treatment for patients with carotid stenotic disease lies in decreasing the risk of disabling * Corresponding author. Tel.: +011-31-503613382; fax: +1-31-503611745. E-mail address: czeebregts@hotmail.com The American Journal of Surgery 195 (2008) 259 –269 0002-9610/08/$ – see front matter © 2008 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.07.022