Treatment of atherosclerotic disease at the cervical carotid bifurcation: current status and review of the literature.

Carotid endarterectomy is increasingly used to decrease the risk of stroke associated with cervical atherosclerotic stenosis, and some investigators claim that the results and benefits for carotid stenting are comparable with those of endarterectomy. A review of the literature reveals that there is incomplete knowledge concerning carotid artery atherosclerotic disease, its associated risks, the optimal medical therapy, indications for intervention, and the optimal interventional procedures. No trial has evaluated the currently available ‘‘best medical therapy’’ or compared it with endarterectomy. Current data indicate that carotid endarterectomy as it is presently practiced in the United States bears little relationship to the populations studied, methods used, or results obtained in the North American Symptomatic Carotid Endarterectomy Trial and Asymptomatic Carotid Atherosclerosis Study. There is a high level of interest in carotid stenting, but there is a lack of definitive proof of safety, efficacy, and durability. Carotid stenting can be performed with a reasonable degree of safety, but until it is clinically validated, carotid stenting should be reserved for patients who are at high risk for stroke. Cervical carotid artery atherosclerotic disease is a correctable cause of stroke, and recent controlled trials of surgical endarterectomy for carotid stenosis have shown its benefit (1–5). Some investigators claim similar morbidity and mortality rates with endovascular treatment, leading to the hope that less invasive therapies will be equally effective for the treatment of carotid stenosis (6–8). The recently published ‘‘Carotid Stenting and Angioplasty: A Statement for Healthcare Professionals from the Councils on Cardiovascular Radiology, Stroke, Cardiovascular Surgery, Epidemiology and Prevention, and Clinical Cardiology, American Heart Association’’ (9) presented several important considerations concerning this developing area of medical