High-risk patients for carotid endarterectomy: The candidates for carotid angioplasty and stent placement

Stroke ranks as the third leading cause of death, behind diseases of the heart and cancer.^1,2 Approximately 750,000 people experience a stroke annually, costing an estimated $40 billion in direct and indirect costs. By the year 2050, an estimated 1 million persons will suffer from stroke every year due to changes in age and ethnic distribution.³ Approximately 25% of these ischemic events are related to occlusive disease of the cervical internal carotid artery.⁴ Carotid atherovascular stenosis increases the risk of ischemic stroke by acting as an embolic source and/or causing hypoperfusion of the ipsilateral cerebral hemisphere. Carotid endarterectomy (CEA), first performed by DeBakey in 1953,⁵ involves arteriotomy of the cervical carotid artery with subsequent removal of athersclerotic plaque. This procedure has been shown to substantially reduce the risk of stroke associated with high-grade carotid stenosis.^6-8 During the last few years, carotid angioplasty and stenting (CAS) has evolved as an alternative to CEA, particularly in patients who are known to have a higher complication rate with CEA.^9,10 The aim of this paper is to briefly review the indications and limitations of CEA, and show how CAS could be a safe and viable alternative in the management of high-risk CEA candidates.