What is the current status of angioplasty vs endarterectomy in patients with asymptomatic carotid artery disease?

Most national and/or specialty driven guidelines recommend against the use of carotid angioplasty/stenting (CAS) in the management of otherwise low or standard risk patients with asymptomatic carotid disease outwith the protection of randomised trials. Despite this relatively clear advice, however, an increasing number of registries and single-centre series now include an ever increasing proportion of low-risk asymptomatic patients within their study cohort. Can this practice currently be justified in the absence of any quality randomised trial evidence? This paper reviews the primary and secondary analyses from the two major randomised trials in asymptomatic patients, discusses the current status of CAS and endarterectomy and highlights areas of controversy and consensus. It concludes with an appeal for all surgeons and interventionists to participate in one of the four randomised trials currently being performed around the world, so that future practice is driven by evidence rather than intuition.