The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) comparing CAS with CEA demonstrated a similar reduction in stroke between the two procedures in symptomatic and asymptomatic patients. In addition, when statins were started on asymptomatic patients prior to CEA, the incidence of perioperative stroke and early cognitive decline also decreased.Ĭarotid artery stenting (CAS) is the alternative treatment for stenosis that became widely available after the year 2000. Trials combining CEA with statin therapy started on hospital admission for surgery showed a decrease in neurologic events such as ischemic stroke and decreased mortality after CEA. With the advent of statin (HMG-CoA reductase inhibitors) therapy, studies demonstrated a decreased risk of major vascular events such as stroke and that more aggressive statin treatment further decreased that risk by an additional 16%. The Asymptomatic Carotid Surgery Trial 1 (ACST-1) demonstrated a 10-year benefit in stroke reduction in asymptomatic patients who underwent CEA for severe stenosis between 70% and 89%. Other studies, both here and abroad, confirmed the benefit of CEA and validated the role of this procedure. The ACAS (Asymptomatic Carotid Atherosclerosis Study) also showed a reduction in incident stroke for asymptomatic patients with 60% or more stenotic lesions but, like the moderate range of stenoses in the NACSET, there was only a 5.8% reduction over 5 years.
Subsequent data from the NASCET reported improvement in outcome with CEA in patients with 50% to 69% stenosis, although the amount of improvement was far less than was the case with higher grade stenosis. The NASCET (North American Symptomatic Carotid Endarterectomy Trial) demonstrated that CEA resulted in an absolute reduction of 17% in stroke at 2 years when compared with medical therapy in symptomatic patients with 70% or greater stenosis. In the 1990s, many large, well-controlled, multicenter trials both in North America and Europe confirmed the effectiveness of CEA in preventing stroke in patients with ICA stenoses as compared with optimized medical therapy.
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