LAUSR

The ancient Greeks had it right. Even today, identifying the best strategy for treating carotid artery disease is still a bit stupefying. This starts at the top! Who is even a candidate for invasive therapies when one factors the percentage of stenosis, symptom burden, gender, carotid and aortic anatomy and more. Never mind the ongoing tension between surgical carotid endarterectomy (CEA) and transcatheter carotid artery stenting (CAS). Fortunately, there is recent help. The European Stroke Organization (ESO) in May 2021 released the most current updated guidelines which give direction by virtue of answers to specific patient scenarios. In summary, there is moderate quality evidence for CEA in patients with ≥60%–99% asymptomatic carotid stenosis over medical therapy. In addition, they recommend symptomatic patients with ≥70%–99% stenosis (high evidence) and ≥50%–69% (low evidence) to undergo CEA. The ESO also recommends (based on high quality evidence) that CEA should be performed early, ideally within 2 weeks of any ischemic event. Where does that leave CAS? Multidisciplinary guidelines have largely relied on the results of the CREST (Carotid Revascularization Endarterectomy versus Stenting Trial) and SAPPHIRE (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy) studies which found no difference between CEA and CAS in terms of stroke, death or MI in long‐term follow‐up. However, there is some evidence for increased periprocedural stroke or death in the CAS group leading many guidelines to recommend CAE over CAS. A large meta‐analysis encompassing over 300,000 patients showed that the risk of procedural stroke/death following CEA has decreased substantially with improved medical therapy and periprocedural stroke prevention while there was no evidence of a change in stroke/death rates following CAS. The aforementioned ESO guidelines state (based on low quality evidence) that CAS may be considered in patients <70 years old with symptomatic ≥50%–99% stenosis. However, CAE is at this time largely preferred. ESO guidelines do confirm that with an ongoing CREST‐2 trial comparing CAS versus medical therapy as one of the arms in the ongoing carotid revascularization and medical management for asymptomatic carotid stenosis trial, there may be further clarification into superiority of one invasive therapy over the other. In this issue of CCI, Varabella et al. dive into an even grayer space where there is also significant debate—where does CAS fit in treating older (>75 years) patients? Their report offers some light into the subject. Importantly, it is based upon a single center, single operator data base investigating in particular the difference in outcomes between those >75 years of age or those <75 when undergoing CAS. They compared 272 patients (>75 years of age) versus 308 patients (<75 years of age) comparing their periprocedural and long‐term outcomes. What they found is not surprising—more complex anatomy with type III aortic atherosclerotic disease or very calcified aortic arches in the older population. Despite this, the rates of 30‐dayMACCE did not differ significantly between the two groups. However, there was a higher rate of death (1.5% vs. 0%) and cerebral hemorrhage (1.8% vs. 1.3%) in the elderly group. These differences may arguably not be clinically important. Longer term follow‐up (median follow‐up of 2 years) showed higher rates of mortality in the elderly group which is also not unexpected—in general, older people tend to die more than a younger group. The low outcome rates in the Varabella report are testimony to the skill of the operator as well as the expertise of their Heart Team in reviewing and choosing CAS candidates. Such outcomes might serve as a benchmark for centers undertaking CAS. Their report offers some added evidence and support for centers with expert operators and a dedicated Heart Team approach to explore CAS regardless of age. However, the small number of events and limitations of results from a single operator will require us to wait for further large‐scale randomized trials, some of which are on the horizon, to further answer these important questions.