Fire in the hole: carotid stenting versus endarterectomy.

Carotid artery stenting has weathered a withering attack during the past year.1,–,3 Comparisons of the 3 recent randomized trials from Europe comparing carotid stenting with endarterectomy in symptomatic patients4,5 lead many to favor endarterectomy.1,–,3 The other 2 trials from North America included a mix of symptomatic and asymptomatic patients with carotid stenosis,6,7 and suggest more muted differences, pointing to equivalence or at least equipoise between the 2 modes of revascularization (Figure). This transatlantic tug-of-war is particularly focused on the importance of adequate training and experience in stenting among operators, the different end points between these trials, and patient selection. Figure. Individual and pooled absolute risk reduction (carotid artery stenting – endarterectomy) for any stroke or death. Intention-to-treat analysis of events from randomization to 30 days postprocedure, stratified by symptoms and operator credentialing (from review of 20 or more carotid procedures) in the recent randomized trials.4–,7,14–,17 Analysis was performed using the STATA statistical package with random-effects model and heterogeneity assessed by the I-squared statistic. CAS indicates carotid artery stenting; CEA, carotid endarterectomy; ARR, absolute risk reduction; EVA-3S, Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis; SPACE, Stent-Protected Angioplasty versus Carotid Endarterectomy; SAPPHIRE, Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy; CREST, Carotid Revascularization Endarterectomy Versus Stenting Trial; and ICSS, International Carotid Stenting Study. As with carotid endarterectomy, adequate operator training, credentialing, and auditing are important aspects of carotid stenting.2 Credentialing to select surgeons with low complication rates was a major feature of the randomized trials of endarterectomy in comparison with medical therapy 2 decades ago.8–,13 The minimization of periprocedural stroke and death permitted an assessment of …