Management of atherosclerotic extracranial carotid artery stenosis.

Atherosclerosis leading to stenosis of the internal carotid artery is the underlying cause of 8-15% of ischaemic strokes (symptomatic carotid stenosis). 1-2% of the adult population have asymptomatic carotid stenosis. Clinical trials in patients with symptomatic carotid stenosis showed a higher procedural risk of non-disabling stroke with stenting versus endarterectomy, but a higher risk of myocardial infarction, cranial nerve palsy, and access site haematoma with endarterectomy. Apart from procedural complications, both treatments are equally effective in preventing stroke and recurrent severe carotid stenosis in the medium-to-long term. Endarterectomy has a modest effect in preventing stroke among patients with asymptomatic carotid stenosis, whereas the role of stenting remains to be established. With advances in medical therapy against atherosclerosis, benefit from invasive therapy has become uncertain. Risk modelling, with the inclusion of brain and carotid plaque imaging, will become increasingly important in selecting patients for interventions.

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Declaration of interests LHB has received grants from Swiss National Science Foundation, University of Basel, Swiss Heart Foundation, and AstraZeneca; personal fees from Amgen, Bayer, Bristol-Myers Squibb, Claret Medical, and InnovHeart; and non-financial support from AstraZeneca and Bayer. OJ has received personal fees from Acandis. The other authors declare no competing interests.