Symptomatic carotid stenosis. The endovascular of surgical treatment

Symptomatic carotid stenosis. The endovascular of surgical treatment The carotid stenting is often considered, without real scientific evidence, as a valuable alternate technique of revascularization and endarteriectomy. Three randomized clinical trials compared the surgical endarteriectomy with endovascular stenting in patients with symptomatic tight atheromatous carotid stenosis. The EVA3-S trial has been stopped, after inclusion of 527 patients, in reason of an excess of strokes or deaths at day 30 in the arm endovascular stenting vs. the surgical one. In the SPACE trial, the rate of stroke or death at day 30 was 7,7% in the arm "endovascular stenting" vs. 6,5% in the surgical arm (statistically non inferior). Results from both studies evidenced that the endovascular treatment did not have the same level of safety than the surgical one. Moreover, preliminary results of the ICSS trial evidenced, after carotid stenting, a percentage of stroke or death of 8,5% in the group "stent" and of 4,7% in the group "endarteriectomy" (p = 0,001). Meta-analyzes of these three trials confirmed the significant superiority of surgery and showed an increased relative risk of stroke, death and myocardial infarction in patients randomized in the "endovascular treatment" arm. In these three clinical trials, the endovascular treatment did not reach the level of safety required by the experts (stroke and death 6%). The only evidenced superiority of the stenting procedure was related to the lower surgical risk of hematomas and of lesions of cranial nerves. Thus, there is no doubt that the endarteriectomy is, and must remain today, the preferred technique of revascularization in patients having a symptomatic tight atheromatous carotid stenosis. Further studies are needed to evaluate the risk of subclinical cerebral infarction and, finally, the global morbid-mortality and the cost of surgery following the failure of the surgical and the endarteriectomy techniques in addition to the occurrence of death and stroke.