CEA vs CAS

Objectives: Last years registered an increment in the number of endovascular procedures. Traditional carotid endoarterectomy (CEA) is the most performed surgical treatment for carotid stenosis. In symptomatic patients CEA reduces significantly absolute relative risk of stroke and death. In asymptomatic patients AHA guidelines recommend CEA for stenosis 60–99%, if the risk of perioperative stroke or death is <3%. According to 2007 Clinical Expert Consensus Document Carotid Artery Stenting (CAS) should be used in patients at high-risk for CEA or into controlled trials and Cochrane Database of Systematic Reviews does not support a widespread change in clinical practice away from recommending CEA as the treatment of choice for suitable carotid artery stenosis. Methods: Large series about CEA, published in the last years, show a trend about a sensible reduction of neurologic complications or death, even below one percent. Several studies have been addressed to evaluate relative role of CEA and CAS. In carotid occlusive disease treatment SPACE and EVA-3S failed to demonstrate superiority of CAS vs. CEA. More studies are still enrolling patients but some of them, as WALLSTENT, SAPPHIRE, SPACE and EVA-3S, have been stopped for excessive complication rate in the CAS limb independently from patient subset and EDP stent. Results: Although the impact on stroke remains unestablished, results are consistent with a clinically important increase in stroke risk with CAS, an intervention that aims at reducing the risk of stroke 2 In a recent review of 32 studies comprising CAS and CEA, the incidence of any new Diffusion- Weighted Imaging lesion was significantly higher after CAS (37%) than after CEA (10%). After two years’ follow-up SPACE trial showed as the rate of recurrent ipsilateral ischaemic strokes is similar for both treatment groups and the incidence of recurrent carotid stenosis is significantly higher after CAS. EVA 3S after four years’ follow-up showed that cumulative probability of periprocedural stroke or death and non-procedural ipsilateral stroke was higher with CAS. After the periprocedural period, the risk of ipsilateral stroke was low and similar in both treatment groups. Open question regarding CEA still exist in particular about shunt, technique and anaesthesia. Conclusions: Today CEA is the best treatment until uncontroindicated. Current data, Cochrane and AHA support CAS procedures for TRIALS enrollment or for CEA contraindications. Indications both CEA or CAS should have the same criteria. For asymptomatic patients still remain debate in the choice of CEA, CAS or best medical treatment.