Management of carotid artery disease in the high-risk patient with emphasis on the SAPPHIRE study.

Ischemic stroke threatens public health dramatically, and demographic changes promise to continue this epidemic. Although medical advances in risk factor modification, hypertensive control, and antiplatelet therapy have mitigated morbidity and mortality of cerebrovascular disease somewhat, stroke still costs billions in healthcare dollars and reduces quality of life for many patients immeasurably. Carotid endarterectomy has been the standard for invasive management of carotid atherosclerosis, successfully reducing risk of stroke in asymptomatic and symptomatic patients. Despite this, many patients are at high risk for surgical intervention and have unacceptable outcomes. Fortunately, carotid artery stenting offers a less invasive and safer option for these patients. Given the recently published SAPPHIRE trial and other clinical trial data, it is likely that carotid artery stenting will supplant carotid endarterectomy for high-risk patients who require carotid revascularization.