Is surgery still generally the first choice intervention in patients with carotid artery disease?

Five randomised trials (RCTs) provided the Level I, Grade A evidence which underpins (to this day) international guidelines regarding the roles of carotid endarterectomy (CEA) and best medical therapy in patients with symptomatic and asymptomatic carotid disease. However, since these trials were published, carotid angioplasty with stenting (CAS) has emerged as a viable alternative and triggered a completely new controversy. CAS offers potential advantages over CEA, but no fewer than eight RCTs have (so far) failed to translate ‘potential’ into clinical reality. More worryingly, some have questioned whether they ever will. The question posed for this debate is whether ‘CEA should still remain the preferred first line intervention’. In order to answer this, it is essential to consider the evidence (separately) for patients deemed ‘standard risk’ (i.e. those randomised in ECST, NASCET, ACAS and ACST) as distinct from patients who are otherwise considered ‘high risk’. The available evidence suggests that CEA remains the ‘gold standard’ in otherwise ‘standard risk’ patients outwith participation in RCTs. It is, however, likely that CAS could become the preferred intervention in selected ‘high risk for surgery’ symptomatic patients. However, evidence supporting a role for either CEA or CAS in ‘high risk for surgery’ asymptomatic patients remains poor. Many are probably best being treated conservatively.