Atherosclerosis is a degenerative disease of the cardiovascular
system that affects approximately half of the world population
. When this disorder affects the carotids, it is responsible
for about 25% of strokes, which are the second main cause
of death around the world. It is also a cause of total or partial
neurological impairments, mainly in the elderly . The World
Health Organization (WHO) predicts that smoking, diabetes
mellitus, hypertension and obesity tend to greatly increase the
number of atherosclerosis cases .
At the beginning of the 20th century, the relation between
carotid atherosclerosis and cerebral ischemia was proved
through thromboembolism. Fifty years later, Carrea, Molins
and Murphy proposed the first surgery for endarterectomy
. Endarterectomy is an incision in the obstructed vessel for
removing the atherosclerotic plaque, the thrombus with its
vascular endothelium. When this procedure is concluded, the
artery is sutured, the blood flow is released and bleeding is
Several studies have proved that surgical treatment is superior
to clinical treatment in patients with severe stenosis. The
most important trials in this field were the European Carotid
Surgery Trial, the North American Symptomatic Carotid
Trial (which included symptomatic patients), and The
Veterans Administration Asymptomatic Trial (which included
the asymptomatic ones) . Endarterectomy was for the
asymptomatic ones, whose stenosis ≥ 70%, according to WHO.
Thus, about a million of endarterectomies were performed only
between 1974 and 1985 .
Angioplasty procedures have recently been considered to have
the advantage of being less interventionist. Carotid angioplasty
is based on the insertion of a guidewire into the vessel. This
wire is used to conduct a self-expandable metal stent which is
positioned and deployed in the stenotic area. It is preferably
introduced through the femoral artery so that it does not interfere
with neurovascular structures which might be susceptible to
injury during surgery.
There are several advantages when we use angioplasty instead of
the classic surgical procedure. In order to perform angioplasty,
only local anaesthetic is usually used, so it could be a better
choice within higher risk patients that could have problems with
deeper sedation; it requires only a short period of recovery;
patient is discharged from the hospital usually within 24 to
48 hours; less risk of cranial nerve damage; less risk of post
procedure infection; less risk of surgical related haematomas; it makes the monitoring of the clinical and neurological status
of the patient more reliable. Thus, this has been the procedure
of choice for patients with severe comorbidities and with a
high risk for endarterectomy. High-risk patients are considered
those with contralateral carotid occlusion, post endarterectomy
restenosis, radiation-induced stenosis, previous cervical
dissection or surgically inaccessible injures. This procedure
has shown good postoperative results, especially after the
development and systematic use of distal protection filters that
prevent post-operative strokes due to thromboembolism caused
by the manipulation of the atherosclerotic carotid plaque .
Many studies have been made which compare the two
therapeutics methods. The biggest of these is the CAVATAS
(Carotid and Vertebral Artery Transluminal Angioplasty Study),
a randomized multicentre study which involved 504 patients;
253 of these were submitted to surgical treatment and 251 to
endovascular treatment (most of them without stents). Eightyeight
per cent of the endovascular group and 91% of the surgical
group were symptomatic patients. The incidence of stroke or
death was 9.9% in the endarterectomy group and 10% in the
angioplasty group. So, this first big study about the technique
showed excellent results, once the use of stents and filters were
The SAPPHIRE, another multicentre study utilized only
procedures of angioplasty with stents and cerebral distal
protection filters. A total of 334 patients were enrolled, 167 in the
endovascular group and 159 in the surgical group. The 30-day
complication rate was 12.2% and 20.1% in the angioplasty and
surgery groups respectively. This trial showed the superiority of
endovascular therapy in relation to endarterectomy associated
with stents and cerebral protection .
A recent meta-analysis of five studies showed that in a total of
1,157 randomized patients, there was no significant difference
in the rate of stroke and death between the two techniques: 8.6%
in the endovascular group versus 7.1% in the surgical group.
Of the three studies that provided information regarding stroke
evolution, 6.0% of patients treated with stents died or had
severe sequelae versus 5% in the surgical group. When AMI
was included, there was no statistically significant difference
between the two groups . Nerve damage occurred in 7.2% of
the surgery group and zero percent in the stent group.
But possibly the most recent and important trial was the CREST
study which, like other studies, demonstrated inexpressible
differences between the stent group and the endarterectomy one,
in relation to unfavourable cardiovascular outcomes. This study
involved 2502 patients at 117 centres in the USA and Canada.
The incidence of primary endpoint at a mean follow-up of 2.5
years did not differ significantly (7.2% for angioplasty versus
6.8% for surgery). However, the 30-day incidence of stroke or
death was 4.4% and 2.3% for endovascular and endarterectomytreated
(symptomatic and asymptomatic patients), respectively,
a difference that was significant. The incidence of myocardial
infarction was significantly higher in endarterectomy than in
angioplasty treated patients (2.3% vs 1.1%). Thus, the increase
in stroke incidence with angioplasty may be offset by an
increase in acute myocardial infarction with endarterectomy
. In 2016, with a 10-year follow-up, it could be seen that the
similarity between the groups was maintained, demonstrating
the safety of angioplasty intervention . It should also be
noted that economic reason should not be a determining factor
for choosing the procedure, since the differences between the
two are insignificant .
Currently, new studies have been published showing that the
carotid stent is effective not only in large trials, but also in the
clinical practice of experienced centres in general .
In conclusion, it can be stated that since the first comparative
studies of the two techniques, there has been a significant
evolution of the techniques and devices used in carotid
angioplasty with stent implantation. Carotid angioplasty
with stent implantation has, today, similar results to those of
endarterectomy surgery in terms of mortality and occurrence of
stroke in the near, medium and distant future.
Thus, the best treatment choice nowadays should be based
not only on the results of the previous studies described here,
but also on the analysis of individual factors such as those of
patient's preference, patient's profession (and need of a natural
voice) comorbidities, age and surgical risk, bleeding risks,
previous radiotherapy applied to the neck, previous surgical
treatment of the cervical region, presence of contralateral carotid
permeability, degree of contralateral collateral flow, degree of
carotid tortuosity (both pre- and post-injury), degree of carotid
calcification, presence of thrombus at the level of the lesion,
degree of obstruction, possibility of adequate use of embolic
protection devices and, especially, adequate surgical or vascular
access to perform the procedure.
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