ABSTRACT
Introduction Carotid endarterectomy (CEA) is one of the most significant and arguably among the best vascular reconstructive operations in our specialty. It is also nothing short of an icon for evidencebased medicine. But it is not without challenge. An estimated 10-20% of CEA procedures are done on so-called “high-risk” (HR) patients – especially those with unfavorable vascular or neck anatomy. Medical co-morbidities (mainly cardiac and pulmonary) can also increase risk or even preclude performance of CEA, albeit infrequently. Another difficult question is whether community-based and low-volume operators can reproduce the surgical results achieved at centers of excellence. And last but not least, CEA – as good as it may be – is “another” standard open operation, and as such is viewed with suspicion and increasing disdain by those who glorify all things endovascular and less invasive. This was the backdrop against which carotid stenting (CAS) evolved over a 20-year period. But it was really during the past 6 to 8 years that CAS “came of age,” due in large part to the development of embolic protection technologies that have since become a critical component of every carotid stent procedure. Further improvements in techniques and equipment will undoubtedly occur, but they are likely to be evolutionary and not revolutionary. We can state with some confidence today that the degree of technical standardization and equipment refinement that have been achieved so far with CAS are quite impressive and (perhaps) near optimal. They provide a solid foundation for a discussion of the topic at hand.
