Carotid-Artery Stenting versus Endarterectomy

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Abstract
To compare protected carotid-artery stenting with carotid endarterectomy, Yadav et al. (Oct. 7 issue)1 chose to study a group for which endarterectomy has been found to be only marginally better than medical therapy.2,3 Although the population was defined as having a high risk on the basis of associated medical conditions, the patients were not at a high risk for stroke on the basis of symptoms and carotid-artery anatomy. More than 70 percent of the patients were asymptomatic, with an estimated carotid-artery stenosis of at least 80 percent of the luminal diameter. For symptomatic patients, a carotid-artery stenosis of only 50 percent was required. In such patients, the expected advantage of endarterectomy over medical therapy would be only 1 to 2 percent per year.2,3 The absence of a medical control group is justified by the small statistical advantages previously found in a similar population.2,3 However, because 12.2 percent of the patients who received a stent had died or had had a stroke or myocardial infarction at one year, it is not clear that medically treated patients would have fared much worse.