We read with interest the paper from Pereira et Al "A Potential Pitfall in the Use of the Monorail System for Carotid Stenting". While the paper focuses on technical aspects of endovascular procedures, we would like to comment on certain aspects related to the clinical indication of carotid stenting (CAS) in the patient reported by the authors. In the late 1980s carotid endarterectomy was controversial. No rigorous data documented its efficacy although many studies reported high complication rates, with one large study by Medicare reporting that 32% of the procedures were performed for inappropriate indications. In the 1990s the ECST and NASCET trials reported a clear surgical benefit in patients with greater than 70% stenosis. In patients with 50-69% stenosis the 5-year risk of any stroke or vascular death was only reduced by 5.7% in the NASCET trial. Hence in this group, surgery is only indicated in patients without clear response to medical therapy. Recentely, CAS has emerged as an alternative to conventional surgical therapy in high-risk patients. This method is currently under evaluation as an alternative to carotid endarterectomy for patients with severe carotid artery stenosis (greater than 70%), and some randomized trials have been recently published.
展开▼
