Is carotid artery stenting a fair alternative to carotid endarterectomy for symptomatic carotid artery stenosis? A commentary on the AHA/ASA guidelines.

UNLABELLED: The recent guidelines by the American Heart Association/American Stroke Association (AHA/ASA) and several other associations recommended carotid artery stenting (CAS) as an alternative to carotid endarterectomy (CEA) for symptomatic patients (Class I; LEVEL OF EVIDENCE: B). The term "alternative" may easily be misinterpreted as "equivalent" to justify the widespread use of CAS. However, current evidence indicates that for symptomatic patients, CAS produces inferior outcomes compared with CEA. It is likely that with technical improvements, better patient selection, and better physician experience, CAS outcomes will improve in the future. CAS may then become a fair alternative to CEA, at least in certain patient subgroups. Based on current evidence, however, we are not there yet and it seems unfair to spin the AHA/ASA guidelines to conclude that we are.