Recent advances in carotid angioplasty and stenting.

Atherosclerotic carotid stenosis accounts for about 15% of ischemic strokes. Carotid endarterectomy reduces the risk of stroke in patients with severe carotid stenosis. Carotid artery stenting has emerged as a potentially less invasive alternative to carotid endarterectomy. However, randomized clinical trials in patients with symptomatic stenosis have shown that carotid artery stenting is associated with a higher risk of peri-procedural stroke compared with carotid endarterectomy. Carotid artery stenting is associated with a lower risk of peri-procedural myocardial infarction and local complications (cranial nerve palsies, access site hematoma) and appears to be as durable as carotid endarterectomy in terms of long-term protection against ipsilateral stroke and risk of restenosis. The main risk factors for peri-procedural stroke in patients treated with carotid artery stenting are age >70 years and high burden of white-matter lesions on brain imaging. Patients with asymptomatic carotid stenosis receiving modern medical treatment have a low risk (<1%/year) of ipsilateral stroke and it is uncertain whether the benefit of revascularization still justifies the procedural risk of stroke or death. In particular, the small excess of procedural risk of stroke associated with carotid artery stenting (compared with carotid endarterectomy) may offset the small benefit (if any) of carotid endarterectomy versus medical therapy in unselected patients. Randomized clinical trials are ongoing to solve this issue.