Sténoses carotides : chirurgie, stenting ou traitement médical ?

There is growing evidence that, thanks to advances in preventive medical therapy for vascular diseases, the annual risk of ipsilateral stroke in medically treated patients with asymptomatic carotid stenosis has declined significantly during the last 20 years and is now much lower than that reported in randomized clinical trials. Therefore, the small benefit of surgery in asymptomatic carotid stenosis observed in early trials is likely to have decreased further, obviating the need for carotid endarterectomy in many patients with carotid disease. Several randomized clinical trials are underway to assess patients with asymptomatic carotid stenosis who benefit from the addition of CEA or CAS to optimal medical treatment. Pending results from these trials, carotid revascularization should only be considered in patients with ACS at higher-than-average risk of stroke, based on information provided by non-invasive imaging techniques, and a high-predicted 5-year survival probability. Randomized clinical trials and registries in patients with symptomatic carotid stenosis have consistently shown that carotid stenting is associated with a higher risk of procedural stroke compared with carotid surgery. Both procedures are equally effective to prevent late recurrent ipsilateral stroke and are associated with similar low risk of restenosis. Although carotid surgery remains the standard treatment in patients with recently symptomatic carotid stenosis, carotid stenting may be considered in patients younger than 70 or when a contraindication for CEA exists.