Role of carotid stenting in management of carotid bifurcation disease: was the revolution overstated?

At its advent, carotid artery stenting (CAS) was widely touted by some as a revolution in the revascularization of severe carotid artery disease, destined to replace carotid endarterectomy (CEA). However, 15 years after the early phases of CAS, it still has only a limited role in carotid therapy in the US. This article will explore the reasons why, which are related to expert operator availability, early trials (largely EU based) that did not support the safety of CAS but which were confounded by a variety of factors which severely limited a true assessment of CAS outcomes, mandatory time-lines involved with regulatory approval, technique and patient selection, and Medicare non-coverage for the multiple FDA-approved devices except for a very select population of patients. The recent publication of the CREST study, and the subsequent FDA Devices Panel presentation of additional analyses, demonstrates equivalent safety and long-term stroke prevention efficacy. This, combined with the adjunct morbidity associated with CEA including cranial nerve injury and excess incisional site complications, suggests that, assuming FDA and CMS approvals, that CAS is poised to have a greater place in the management of the carotid patient.