Symptomatic Carotid Stenosis: Endarterectomy,
Stenting, or Best Medical Management?
James F. McKinsey, MD, FACS
In the past, management of symptomatic carotid stenosis was uncertain. The results of the
North American Symptomatic Carotid Endarterectomy Trial (NASCET) in 1991 demon-
strated a significant advantage of Carotid Endarterectomy (CEA) compared to medical
management with Aspirin (ASA). Since the publishing of the NASCET results, there have
been advances in both the medical management of patients with peripheral arterial disease
as well as the introduction and improvement of the technique of minimally invasive carotid
angioplasty and stenting. With this progress, the question has to be raised about what is
the most appropriate treatment option for patients with symptomatic carotid artery steno-
sis. A review of the prospective clinical trials regarding the medical, surgical and endo-
vascular management will help to elucidate the optimal therapy for symptomatic carotid
stenosis.
Semin Vasc Surg 21:108-114 © 2008 Elsevier Inc. All rights reserved.
T
HERE ARE OVER 700,000 new strokes each year in the
United States, with over 160,000 stroke-associated
deaths,
1,2
making stroke the third leading cause of death in
the United States. Carotid endarterectomy (CEA) was first
reported in the 1950s as a therapeutic option for treatment of
carotid stenosis. Since that time, there have been multiple
studies attempting to define the appropriate management of
patients with symptomatic and asymptomatic carotid steno-
sis. The symptoms that can be associated with carotid steno-
sis are hemispheric in nature, and generally can be divided
into reversible cerebral ischemia, such as transient ischemic
attack (TIA); reversible ischemic neurologic deficit or amau-
rosis fugax (temporary monocular blindness); and neuro-
logic stroke events lasting longer than 24 hours or resulting
in cerebral infarction but are nondisabling. In many series,
those patients with severe disabling stroke (Rankin score Ն3)
have been excluded from enrollment into clinical trials.
Treatment options for patients with symptomatic carotid ste-
nosis include optimal medical therapy, carotid endarterec-
tomy, or carotid stent with angioplasty (CAS), with and with-
out cerebral protection. In the following discussion, we will
focus on these three treatment options.
CEA for Management of
Symptomatic Carotid Stenosis
Multiple trials have attempted to evaluate the role of CEA in
those patients with symptomatic carotid stenosis. T h e t w o
major prospective randomized trials comparing CEA to
optimal medical therapy are the North American Symp-
tomatic Carotid Endarterectomy Trial (NASCET)
3,4
and
the European Carotid Surgery Trial (ECST).
5,6
These two
trials helped to clearly define the role of CEA versus opti-
mal medical therapy for patients with symptomatic carotid
stenosis.
An important distinction between these two trials was the
method used to calculate degree of stenosis. The NASCET
study measured the degree of stenosis by taking the luminal
diameter at the maximal stenosis and comparing it to the
luminal diameter of the portion of the internal carotid artery
in which the carotid arterial walls became parallel distal to the
area of stenosis. Contrary to this, the ECST study approxi-
mated the outer wall diameter at the point of maximum ste-
nosis in the internal carotid artery or carotid bifurcation and
then calculated the true luminal diameter at the area of max-
imal stenosis. The percentage of stenosis was calculated by
dividing the minimal luminal diameter by the estimated
outer wall diameter. This led to a discrepancy between the
two trials, where the NASCET-calculated degree of steno-
sis was somewhat less than the ECST-calculated degree of
stenosis. For example, the same stenosis would be calcu-
lated as 80% stenosis by NASCET calculations, but would
Division of Vascular Surgery, New York Presbyterian Hospital and Columbia
College of Physicians and Surgeons, Weill Medical College of Cornell
University, New York, NY.
Address reprint requests to James F. McKinsey, New York Presbyterian
Hospital, 161 Fort Washington Avenue, Suite 629, New York, NY
10032. E-mail: jfm2111@columbia.edu
108
0895-7967/08/$-see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1053/j.semvascsurg.2008.03.008