Symptomatic carotid artery stenosis: the dilemma for a reasonable selection of carotid stenting or endarterectomy

An excellent meta-analysis from Gurm et al. 1 updates the data concerning the treatment of symptomatic carotid stenosis by a surgical or endovascular approach. The last two randomized trials, SPACE2 and EVA3S,3 did not, in fact, confirmed the equivalence of the two methods and there followed a general unfavourable feeling towards carotid stenting. The article by Gurm et al. , 1 which eliminates some old randomized studies such as CAVATAS4 and the stopped Leicester trial,5 appears statistically sound. We can learn that there is no significant difference between carotid stenting (CAS) and endarterectomy (CAE). Today, the data are heterogeneous and difficult to analyse; the authors have shown that we can approach the truth and keep the two options without bringing them into conflict. Patients with symptomatic tight carotid stenosis have to be treated because the risk of a cerebrovascular accident is ∼20% at 1 year. In the 1980s, surgical treatment was compared with medical treatment by lengthy randomized trials such as NACST6 and ECST,7 and has been recognized as the reference treatment. The contribution of antiplatelet agents and statins today offers much better patient care for atherosclerotic disease and raises questions about the validity of these outdated studies. CAS is still in evolution, with a … Corresponding author. Tel: +33 49180 69 05, fax: +33 49180 69 26. Email: pbergeron{at}hopital-saint-joseph.fr; endovasc{at}hopital-saint-joseph.fr