Shrinking Role for Carotid Revascularization in Stroke Prevention

The surgical or endovascular treatment of patients with asymptomatic atherosclerotic carotid artery stenosis has become controversial, given the advances in medical treatment since the original pivotal trials establishing efficacy for surgical endarterectomy. The ECST-2 (European Carotid Stenosis Trial-2) recently reported no benefit of revascularization procedures over modern medical treatment alone. In addition, its findings extend to lower-risk symptomatic patients. These data add a brick to the wall supporting medical management alone for these 2 patient populations. Future work should focus on identifying patients most likely to benefit from revascularization—shifting from traditional anatomic criteria such as percent diameter stenosis to patient-specific risk factors, including physiological and hemodynamic information.