Carotid Artery Stenosis – Endarterectomy or Stenting?

Authors: V. Beneš 1;  D. Netuka 1;  F. Charvát 2;  M. Mohapl 1;  F. Kramář 1;  S. Ostrý 1;  J. Mašková 2;  J. Lacman 2
Authors‘ workplace: Neurochirurgická klinika 1. LF UK, IPVZ a ÚVN Praha 1;  Radiodiagnostické oddělení ÚVN Praha 2
Published in: Cesk Slov Neurol N 2008; 71/104(4): 388-399
Category: Minimonography

Podpořeno IGA MZCR NR/9435-3.


In past years, carotid artery stenting (CAS) has been receiving much attention in the treatment of carotid stenosis. CAS is spreading fast and, both scientific and lay communities are under the impression that CAS will soon replace carotid endarterectomy (CEA). Treatment of carotid artery stenosis by both CEA and CAS is not difficult, but it must be performed as an institutional programme and requires teamwork. We feel it is appropriate to summarise the current state of affairs in the form of review. The studies comparing CEA and medical treatment will be summarized first along with the American Heart Association (AHA) recommendations. The randomized studies comparing CEA and CAS will be summarised. Based on published data the authors conclude that CAS is an alternative method to be used in specific situations. The definitive conclusions can be postulated only after the ongoing trials comparing CEA and CAS are concluded and published. Apart from specific situations, CAS should not be indicated outside the ongoing trials and registries. In conclusion; CEA is the treatment of choice for patients with carotid stenosis, provided AHA recommendations are followed. CAS is used in the following specific conditions: 1. carotid re-stenosis, 2. dissections, 3. significant tandem lesions, 4. post-irradiation stenosis and in patients after major neck surgeries, 5. in patients with complex anatomical conditions.

Key words:
carotid artery stenosis – endarterectomy – stenting


1. North American Symptomatic Carotid Endarterectomy Trial. Methods, patient characteristics, and progress. Stroke 1991; 22(6): 711–720.

2. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325(7): 445–453.

3. Gasecki AP, Eliasziw M, Ferguson GG, Hachinski V, Barnett HJ, North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group. Long-term prognosis and effect of endarterectomy in patients with symptomatic severe carotid stenosis and contralateral carotid stenosis or occlusion: results from NASCET. J Neurosurg 1995; 83(5): 778–782.

4. Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB et al (North American Symptomatic Carotid End­arterectomy Trial Collaborators). Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med 1998; 339(20): 1415–1425.

5. European Carotid Surgery Trialists‘ Collaborative Group. European Carotid Surgery Trial: interim results for symptomatic patients with severe (70–99%) or mild (0–29%) carotid stenosis. Lancet 1991; 337(8752): 1235–1243.

6. Warlow CP. Symptomatic patients: the European Carotid Surgery Trial (ECST). J Mal Vasc 1993; 18(3): 198–201.

7. European Carotid Surgery Trialists‘ Collaborative Group. Endarterectomy for moderate symptomatic carotid stenosis: interim results from the MRC European Carotid Surgery Trial. Lancet 1996; 347(9075): 1591–1593.

8. European Carotid Surgery Trialists‘ Collaborative Group. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998; 351(9113): 1379–1387.

9. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid stenosis. JAMA 1995; 273(18): 1421–1428.

10. Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J et al (Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group). Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004; 363(9420): 1491–1502.

11. Moore WS, Mohr JP, Najafi H, Robertson JT, Stoney RJ, Toole JF. Carotid endarterectomy: practice guidelines. Report of the Ad Hoc Committee to the Joint Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery. J Vasc Surg 1992; 15(3): 469–479.

12. Moore WS, Barnett HJ, Beebe HG, Bernstein EF, Brener BJ, Brott T et al. Guidelines for carotid endarterectomy: a multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association. Circulation 1995; 91(2): 566–579.

13. Biller J, Feinberg WM, Castaldo JE, Whittemore AD, Harbaugh RE, Dempsey RJ et al. Guidelines for carotid endarterectomy: a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association. Circulation 1998; 97(5): 501–509.

14. Albers GW, Hart RG, Lutsep HL, Newell DW, Sacco RL. AHA Scientific Statement. Supplement to the guidelines for the management of transient ischemic attacks: A statement from Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks, Stroke Council, American Heart Association. Stroke 1999; 30(11): 2502–2511.

15. Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Stroke 2006; 37(2): 577–617.

16. Rothwell PM, Gutnikov SA, Warlow CP; European Carotid Surgery Trialist‘s Collaboration. Reanalysis of the final results of the European Carotid Surgery Trial. Stroke 2003; 34(2): 514–523.

17. Rothwell PM, Eliasziw M, Gutnikov SA, Fox AJ, Taylor DW, Mayberg MR et al. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 2003; 361(9352): 107–116.

18. Alamowitch S, Eliasziw M, Barnett HJ; North American Symptomatic Carotid Endarterectomy Trial (NASCET); ASA Trial Group; Carotid Endarterectomy (ACE) Trial Group. The risk and benefit of endarterectomy in women with symptomatic internal carotid artery disease. Stroke 2005; 36(1): 27–31.

19. Mayberg MR, Wilson E, Yatsu F, Weiss DG, Messina L, Hershey LA et al (Veterans Affairs Cooperative Studies Program 309 Trialist Group). Carotid endarterectomy and prevention of cerebral ischaemia in symptomtic carotid stenosis. JAMA 1991; 266(23): 3289–3294.

20. Hobson RW 2nd, Weiss DG, Fields WS, Goldstone J, Moore WS, Towne JB et al. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. The Veterans Affairs Cooperative Study Group. N Engl J Med 1993; 328(4): 221–227.

21. Mayo Asymptomatic Carotid Endarterectomy Study Group: Results of a randomized controlled trial of carotid endarterectomy for asymptomatic carotid stenosis. Mayo Clin Proc 1992; 67(6): 513–518.

22. Bond R, Rerkasem K, Rothwell PM. Systematic review of the risks of carotid endarterectomy in relation to the clinical indication for and timing of surgery. Stroke 2003; 34(9): 2290–2301.

23. Rothwell PM, Warlow CP. Timing of TIAs preceding stroke: time window for prevention is very short. Neurology 2005; 64(5): 817–820.

24. Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ (Carotid Endarterectomy Trialists Collaboration). Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004; 363(9413): 915–924.

25. Alamowitch S, Eliasziw M, Algra A, Meldrum H, Barnett HJ (North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group). Risk, causes, and prevention of ischaemic stroke in elderly patients with symptomatic internal–carotid–artery stenosis. Lancet 2001; 357(9413): 1154–1160.

26. White CJ, Iyer SS, Hopkins LN, Katzen BT, Russell ME (BEACH Trial Investigators). Carotid stenting with distal protection in high surgical risk patients: the BEACH trial 30 day results. Catheter Cardiovasc Interv 2006; 67(4): 503–512.

27. Gray WA, Hopkins LN, Yadav S, Davis T, Wholey M, Atkinson R et al (ARCHeR Trial Collaborators). Protected carotid stenting in high-surgical-risk patients: the ARCHeR results. J Vasc Surg 2006; 44(2): 258–268.

28. Fairman R, Gray WA, Scicli AP, Wilburn O, Verta P, Atkinson R et al (CAPTURE Trial Collaborators). The CAPTURE registry: analysis of strokes resulting from carotid artery stenting in the post approval setting: timing, location, severity, and type. Ann Surg 2007; 246(4): 551–556.

29. Katzen BT, Criado FJ, Ramee SR, Massop DW, Hopkins LN, Donohoe D et al (CASES-PMS Investigators). Carotid artery stenting with emboli protection surveillance study: thirty-day results of the CASES-PMS study. Catheter Cardiovasc Interv 2007; 70(2): 316–323.

30. CaRESS Steering Committee. Carotid Revascularization Using Endarterectomy or Stenting Systems (CaRESS) phase I clinical trial: 1-year results. J Vasc Surg 2005; 42(2): 213–219.

31. Naylor AR, Bolia A, Abbott RJ, Pye IF, Smith J, Lennard N et al. Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: a stopped trial. J Vasc Surg 1998; 28(2): 326–334.

32. Alberts MJ. Results of a multicenter prospective randomized trial of carotid artery stenting vs. carotid endarterectomy. Stroke 2001; 32(6): 325.

33. Brooks WH, McClure RR, Jones MR, Coleman TC, Breathitt L. Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital. J Am Coll Cardiol 2001; 38(6): 1589–1595.

34. Brooks WH, McClure RR, Jones MR, Coleman TL, Breathitt L. Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis: a randomized trial in a community hospital. Neurosurgery 2004; 54(2): 318–324.

35. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 2001; 357(9270): 1729–1737.

36. Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ et al (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy Investigators). Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004; 351(15): 1493–1501.

37. Ringleb PA, Allenberg J, Brückmann H, Eckstein HH, Fraedrich G, Hartmann M et al (SPACE Collaborative Group). 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 2006; 368(9543): 1239–1247.

38. Mas JL, Chatellier G, Beyssen B, Branchereau A, Moulin T, Becquemin JP et al (EVA-3S Investigators). Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 2006; 355(16): 1660–1671.

39. Kastrup A, Gröschel K. Carotid endarterectomy versus carotid stenting: an updated review of randomized trials and subgroup analyses. Acta Chir Belg 2007; 107(2): 119–128.

40. Mozes G. High-risk carotid endarterectomy. Semin Vasc Surg 2005; 18(2): 61–68.

41. Luebke T, Aleksic M, Brunkwall J. Meta-analysis of randomized trials comparing carotid endarterectomy and endovascular treatment. Eur J Vasc Endovasc Surg 2007; 34(4): 470–479.

42. Benes V, Netuka D, Mandys V, Vrabec M, Mohapl M, Kramár F et al. Comparison between degree of carotid stenosis observed at angiography and in histological examination. Acta Neurochir (Wien) 2004; 146(7): 671–678.

43. Netuka D, Benes V, Mandys V, Hlásenská J, Burkert J, Benes V jr. Accuracy of angiography and Doppler ultrasonography in the detection of carotid stenosis: a histopathological study of 123 cases. Acta Neurochir (Wien) 2006; 148(5): 511–520.

44. The International Carotid Stenting Study Website [online]. Last revision 24th April 2008. Dostupné z: <>.

45. Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) [online]. Last revision 9th July 2008. Dostupné z: <>.

46. Asymptomatic Carotid Surgery Trial-2 (ACST) [online]. Dostupné z: <>.

Paediatric neurology Neurosurgery Neurology

Article was published in

Czech and Slovak Neurology and Neurosurgery

Issue 4

2008 Issue 4

Most read in this issue
Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.


Don‘t have an account?  Create new account