Indications and therapeutic management of carotid stenosis in high-risk patients: SAPPHIRE and beyond

Carotid artery revascularization is an effective means of stroke prevention in selected patients with carotid stenosis. Traditionally, carotid endarterectomy (CEA) was performed to achieve this goal. With the development of endovascular techniques and technologies, carotid artery stenting (CAS) has become a viable alternative to CEA, particularly in patients considered high risk for CEA. The Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) study single-handedly catapulted CAS to the forefront of therapeutic options for high-risk patients. This study directly compared CAS to CEA in high-risk patients, finding CAS to be equally effective. Since SAPPHIRE, several studies have confirmed the safety and efficacy of CAS in high-risk patients, demonstrating acceptable 1-year morbidity (1-11.3%) and durable target-vessel patency (97.6-98.7%).