CEA vs. stent in patients with acute strokes: are they equally effective?

INTRODUCTION: Stroke is the 3rd leading cause of death worldwide with 15 million strokes annually. Extracranial carotid stenosis contributes to major stroke morbidity and mortality as a significant etiology of ischemic strokes. For acute stroke, in addition to optimal medical management, patients may be candidates for carotid endarterectomy and/or carotid stenting for secondary stroke reduction. This paper set out to review the data currently available regarding equivalency of the two intervention options. EVIDENCE ACQUISITION: A comprehensive literature review was performed through PubMed and other sources using the key words carotid endarterectomy, carotid artery stent, acute stroke, symptomatic carotid stenosis, flow reversal, TCAR. Studies which solely evaluated patients with asymptomatic disease were ineligible for the study. EVIDENCE SYNTHESIS: Review of landmark trials such as NASCET and CREST in addition to more recent studies demonstrates the effectiveness of surgical management with carotid endarterectomy of acute stroke. Carotid stenting has also been shown to have acceptable outcomes in certain patient populations. CONCLUSIONS: Carotid endarterectomy continues to demonstrate effectiveness and safety for management of acute stroke, while carotid stenting has limitations. Carotid artery stenting has been shown to be non-inferior in some patient populations, but more recent and future technologic developments may expand the potential acceptable patient selection criteria.