Ernstige, symptomatische carotisstenose

Comparative studies between carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) for treatment of patients with carotid artery stenosis have thus far been severely hampered by selection bias and even more by lack of experience in the endovascular groups. The two largest trials published so far, SPACE and EVA-3S, have excluded patients deemed to be poor candidates for CEA. These selected patients were subsequently randomised to either CEA by an experienced vascular surgeon or CAS by a relatively inexperienced endovascular interventionalist. The stroke and death rate in SPACE was remarkably similar between groups, whereas in EVA-3S it was significantly lower for CEA. In the SAPPHIRE trial, with highly experienced operators in both groups, CAS was significantly better than CEA, however patients with a high surgical risk were excluded from randomisation. The authors of this article prefer CAS. Realistically, in experienced hands both treatment modalities are probably quite comparable and an individual selection of treatment options is warranted. Patient preference may also play a role in treatment selection.