CAS "Losses" to Endarterectomy: Temporary Setback or has CEA Won?

At the dawn of a new year, it should come as no surprise that yet a further update on the status of carotid stenting (CAS) is warranted. Developments of the past several months appear to have triggered (or quickened the pace of) changes in the carotid landscape, and I cannot say this is unexpected. In fact, the VDM Editor’s Corner in July/August 2006 saw it coming: “… the boundless enthusiasm (for CAS) of the early days is — appropriately — beginning to be tempered by two powerful forces: data and reality!” The truth is that new trial results and the reactions that followed seem to provide considerable ammunition to those who remain skeptical about the value of CAS. More to the point, the outcome of the EVA-3S1 and SPACE2 European clinical trials have caused — one might say — a “pendulum swing-back to carotid endarterectomies (CEA)” as they appear to show slight or clear-cut inferiority of CAS to surgical CEA. Flawed and imperfect as they may be, these studies cannot be simply ignored or tossed out as “irrelevant” or “biased”. And they are not alone in ‘questioning’ the safety and efficacy of CAS when compared to endarterectomy.

So, is this the end of the road for CAS…? Has CEA won?? I would say one cannot but conclude (with rare exceptions) CAS has failed to prove non-inferiority to CEA when all currently available evidence is taken into account. In other words, CEA will remain — undoubtedly — the undisputed standard of care for treatment of most patients in the foreseeable future. But perhaps not forever…. Consider this:

• The “definitive” comparative large trials are only beginning or in the planning stages at present;

• CAS technologies, and embolic protection devices in particular, will continue to improve — perhaps dramatically;

• CEA, on the other hand, has reached a level of optimal performance from where it is unlikely to improve much further;

• Interventionists doing CAS continue to refine the technical conduct of the procedure and, more importantly, learn to select patients who should have surgery (or no intervention at all) instead.

For those of us who have gained large experience and confidence with CAS, there’s little doubt this is an elegant, effective and safe procedure — but only when applied wisely. Having said that, it is important to note that some of the current paradigms, especially those related to unfavorable anatomy, may change in the near future with the development of innovative access and anti-embolic techniques and devices. In the end, it would seem that CAS is definitely here to stay, but its precise role in the management of patients with carotid artery stenosis remains largely undefined. It endures as a “hot political issue” for sure, going from “total triumph” in 2004 to “near-defeat” in 2006… Its future is probably assured but uncertain. However, I would caution vascular surgeons not to repeat the mistake of their interventional colleagues when they “announced” the demise of CEA prematurely….