Carotid artery revascularization in high-risk patients

Carotid endarterectomy (CEA) became an accepted method for carotid revascularization on the basis of early trials, especially the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and Asymptomatic Carotid Atherosclerosis Study (ACAS). Simultaneously, CAS was being proposed as a minimally invasive alternative to CEA, and the proponents of CAS started evaluating carotid artery stenting (CAS) in patients who would have been excluded from participation in the CEA trials. Patients who were excluded from the CEA trials by the investigators were deemed to be at high-risk for CEA based on many years of experience. These beliefs were reinforced by the results of the SAPPHIRE trial and the CAS reimbursement guidelines from the FDA and the CMS. The Food and Drug Administration (FDA) objective performance criteria for CEA were based on an exhaustive literature review, as well as experience factors noted above. Current studies are helping to better define high risk for patients with precise estimates of stroke risks and other CEA-associated risks. As experience with CAS is increasing, there is mounting evidence to identify patients with high-risk for CAS.