Carotid intervention, patient patients

External validity can also be affected if trials have protocols that differ from usual clinical practice. For example, prior to randomization in the trials of endarterectomy for symptomatic carotid stenosis patients had to be diagnosed by a neurologist and to have conventional arterial angiography, neither of which are routine in many centers. The trial intervention itself may also differ from that used in current practice, such as in the formulation and bioavailability of a drug, or the type of anesthetic used for an operation. The same can be true of the treatment in the control group in a trial, which may use a particularly low dose of the comparator drug or fall short of best current practice in some... 

This concern extends to carotid artery stenting. Although carotid artery stenting in patients with asymptomatic CAS can be performed by experienced operators with a low complication rate, the procedure can be associated with high complication rate if performed by inexperienced operators, particularly in older patients with complex anatomy (24). In any case, institution-specific assessment of the risk of carotid intervention, endarterectomy, or stenting should be a prime consideration in clinical decision making regarding carotid revascularization in patients with asymptomatic CAS. 

Due to the very low event rates in patients with asymptomatic lesions of moderate severity (<60% diameter stenosis), it is unknown whether currently available interventional techniques can improve long-term outcomes over those achievable with optimal medical management. Also unresolved are the indications for carotid stenting in asymptomatic individuals with contralateral carotid occlusion (53) and those undergoing major cardiac or vascular surgery (54). 

Although only a minority of patients with TIA or ischemic stroke are potential candidates for carotid endarterectomy (CEA) or stenting, the decision to opt for interventional treatment rather than medical treatment alone can be difficult and is, therefore, given detailed consideration in this Ch. Most of the discussion relates to CEA because far more data are available on the risks and benefits of surgery than for stenting. However, most of the issues discussed are applicable to both procedures. 

Apart from surgical and interventional therapy of occlusive carotid artery disease, the major approach to preventing vascular disease and subsequent stroke is to pay close attention to the control of modifiable risk factors such as hypertension, smoking, diabetes, and hypercholesterolemia. Coumadin, an anticoagulant, is effective for the primary and secondary prevention of stroke in patients with atrial fibrillation. Aspirin, clopidogrel, and the combination of aspirin and cUpyridamole have been proven to be effective for secondary stroke prevention along with the antihypertensive combination of indap-amide and perindopril. 

There is extensive evidence that changes in plasma OxPL/apoB ratios, measured using the murine monoclonal antibody E06 (Tsimikas 2006b Tsimikas and Witztum 2001) may reflect the extent of atherosclerotic disease burden (Tsimikas et al. 2005,2006). It was shown that OxPL/apoB levels are increased in patients with coronary, carotid or femoral artery disease, acute coronary syndromes and after percutaneous coronary intervention (Tsimikas et al. 

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