Carotid revascularization trial

Carotid revascularization, initially by CEA, was introduced in early 1950s as a method to prevent stroke due to atherosclerosis of the carotid bifurcation and internal carotid artery (ICA). At least four prospective randomized trials have demonstrated... 

CARESS Steering Committee (2005). Carotid Revascularization Using Endarterectomy or Stenting Systems (CARESS) phase I clinical trial 1-year results. Journal of Vascular Surgery 42 213-219... 

Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) (2006). Stroke 37 e36... 

Most experts agree that certain patients with asymptomatic CAS are at high risk for stroke and may derive significant benefit from carotid revascularization. Identification of those patients, however, has been elusive in clinical trials. Risk stratification of patients with asymptomatic CAS is particularly important among patients with 60% to 79% stenosis, in whom the appropriate management is more uncertain. Identifying high-risk patients will certainly lead to better resource utilization for both medical and revascularization therapies for patients with asymptomatic CAS. 

Cerebral microembolic signals are detected by tran-scranial Doppler in 1% to 23% of patients with asymptomatic CAS (36-38). The prevalence of cerebral microembolic signals in patients with asymptomatic CAS varies with the severity of the carotid stenosis, the morphology of the carotid plaque, and the frequency and duration of transcranial Doppler monitoring. The presence of cerebral microembolic signals in patients with asymptomatic CAS has been associated with a risk of stroke increased four to five times (38). However, the clinical utility of this technique to discriminate among patients who will benefit from carotid revascularization versus those who would not awaits confirmation in prospective trials. 

Data regarding the role of CAS in low-surgical-risk patients with asymptomatic CAS are limited. The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) lead-in registry has reported data for investigators during the roll-in phase (51). The 30-day rate of stroke and death in the 960 asymptomatic patients was 4.0%, and if limited to only patients under the age of 80 years is 3.3%. The 30-day rate of death and major stroke in patients under the age of 80 years was 1.4%. 

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