Stroke is a major cause of death and disability. Approximately 10% to 15% of ischemic strokes are attributable to atherosclerosis of the internal carotid arteries,1 and there is great interest in surgical and endovascular approaches to stroke prevention. Carotid artery surgery or endarterectomy (CEA) has been the traditional intervention, and carotid angioplasty with stenting (CAS) is the newer percutaneous procedure. Both procedures increase the short-term risk of death or stroke due to the intervention in exchange for a lower long-term risk of stroke.2,3 Therefore, the magnitude and balance of the risks and benefits for these procedures are crucial considerations. Patients with symptomatic disease (ie, those who have had a stroke or transient ischemic attack in the past 6-12 months in the distribution of a carotid artery with ≥50% stenosis) benefit from CEA, which reduces the absolute risk of stroke by 8% per year.4 Asymptomatic patients (those with carotid occlusive disease without neurological symptoms) have a more modest benefit from CEA (absolute stroke reduction of 0.8%-1% per year).5,6 Carotid artery surgery or endarterectomy is considered beneficial only if it can be performed with a 30-day risk of death or stroke of 6% or less among symptomatic patients and 3% or less among those who are asymptomatic.2,3
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