Journal Review in Vascular Surgery: Carotid Revascularization – CEA, Stent or Nothing at All?

Carotid artery disease management has come a long way. From the days when every stroke meant an endarterectomy to a modern era defined by precision, evidence, and evolving technology. With advances in medical therapy and newer techniques like TCAR, the vascular surgeon has even more to consider when choosing the best treatment for carotid disease. Join us as we break down the major landmark trials NASCET, CREST and the Asymptomatic Carotid trials, and discuss how their findings shape our clinical decisions in practice today.

Hosts:
· Christian Hadeed -PGY 4 General Surgery, Brookdale Hospital Medical Center
· Paul Haser -Division Chief, Vascular Surgery, Brookdale Hospital Medical Center
· Andrew Harrington, Vascular surgery, Brookdale Hospital Medical Center
· Lucio Flores, Vascular surgery, Brookdale Hospital Medical Center

Learning Objectives:
· Review the key findings and clinical implications of the NASCET, ACST, and CREST trials.
· Discuss patient selection for carotid endarterectomy (CEA) vs carotid artery stenting (CAS).
· Understand how age, calcification, and aortic arch anatomy affect stenting outcomes or choice between stent and CEA.
· Identify how advances in medical therapy have influenced management of asymptomatic disease.
· Discuss appropriate screening/ follow up plans for patients who do not meet criteria for intervention

References:
- North American Symptomatic Carotid Endarterectomy Trial Collaborators. (1991). Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. The New England Journal of Medicine, 325(7), 445–453. https://pubmed.ncbi.nlm.nih.gov/1852179/
- Brott, T. G., Hobson, R. W. II, Howard, G., Roubin, G. S., Clark, W. M., Brooks, W., ... & Howard, V. J. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. The New England Journal of Medicine, 363(1), 11–23. https://pubmed.ncbi.nlm.nih.gov/20505173/
- Halliday, A., Mansfield, A., Marro, J., Peto, C., Peto, R., Potter, J., & Thomas, D.; MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. (2004). Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: Randomized controlled trial. The Lancet, 363(9420), 1491–1502. https://pubmed.ncbi.nlm.nih.gov/15135594/
- Halliday, A., Bulbulia, R., Bonati, L. H., Chester, J., Cradduck-Bamford, A., Peto, R., & Pan, H., & the ACST-2 Collaborative Group. (2021). Second asymptomatic carotid surgery trial (ACST-2): A randomised comparison of carotid artery stenting versus carotid endarterectomy. The Lancet, 398(10305), 1065-1073. https://doi.org/10.1016/S0140-6736(21)01910-3

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