The established ‘gold standard’ approach to carotid revascularisation remained enshrined as the go-to operation as far as the CX audience gathered in Theatre 3 for a carotid and acute stroke challenges great debate earlier today was concerned.
An overwhelming 76% of those who voted in the post-debate poll sided with Barbara Rantner (Munich, Germany) after she made the case for carotid endarterectomy (CEA), long established as the gold-plated method of tackling carotid disease requiring intervention. Transcarotid artery revascularisation (TCAR) and transfemoral carotid artery stenting (CAS) each drew 12% of the audience share apiece, with the proposition for TCAR put forward by Michael Stoner (Rochester, United States) and that of CAS made by Christopher Metzger (Columbus, United States).
Rantner, a co-chair of the 2023 European Society for Vascular Surgery (ESVS) carotid guidelines, looked at CEA through the prisms of gender, age and timing of procedure. “There is no gender issue, there is no age issue, there are no limitations in timing of treatment,” she declared, pointing out the absence of a superiority trial showing an alternative revascularisation option that has been proven to perform better than CEA. “Is endarterectomy the gold standard? Yes.”
Among the articles she invoked in support, she referenced 10-year ACST-1 trial results that showed surgery equally benefitted male and female asymptomatic patients. Symptomatic females undergoing CAS in CREST, Rantner said, “suffered from significantly higher periprocedural complications” when compared to CEA. Focusing on age, trial analysis showed that CAS was not a benefit for patients aged 65 or older. “Implementing endarterectomy remains standard of care, and also in the elderly population of 80 years and older,” Rantner added. In terms of timing, data demonstrated CAS “very significantly increased risk when we looked at early treatment onset”, she said.
The case for TCAR, meanwhile, rests in its minimal-access benefits for high-risk patients, the fact the procedure takes embolic risk in the aortic arch off the table, its safety profile, which is “as good—or better—than CEA”, the fact that it is “highly reproducible and scalable”, and its “rapid learning curve for contemporary vascular surgeons”, argued Stoner. He led attendees through the three ROADSTER studies which produced data in support of TCAR, and looked at how the procedure compares to CAS. “TCAR is safer than CAS in any trial that has looked at this,” Stoner said. “How does it compare to CEA, the ‘gold standard’? Well, the gold standard doesn’t fare as well as TCAR. We have equivalent stroke/death rates, improved myocardial infarction, pre- and post-procedural hypotension and length of stay, less than one day, and you can see a sustained benefit for TCAR.”
“Percutaneous CAS is plagued by procedural embolic risk and worse outcomes over time in at-risk patients,” Stoner summarised. “TCAR solves the CAS embolic problem. Hard outcomes are equivalent to CEA or even better, and there is a strong patient preference toward minimal access surgery. As such, I’ll submit that TCAR is now the contemporary gold standard for carotid revascularisation.”
Taking up the case for CAS, Metzger reasoned that all of the carotid revascularisation strategies “are excellent” and that there is no single gold standard for the procedure. Clear-cut gains for transfemoral stenting include no general anaesthesia and less stress on older or sicker patients, he said. Disadvantages, on the other hand, include the fact that not all patient anatomies are suitable for CAS, Metzger noted. The case for CAS includes four randomised trials in which the strategy went up against CEA and, in one, medical therapy. “The last four randomised trials of carotid stenting versus endarterectomy have produced outstanding results for both therapies and their equivalent,” he said. With newer carotid stents emerging and contemporary results in CREST-2, “the results keep getting better”.
The three strategies are complementary rather than competitive, Metzger concluded. “We should individualise our approach and, in 2025, with patient selection and good technique, all of these therapies are phenomenal.”
In post-debate discussion, a comment from the audience took issue with Stoner’s description of the ROADSTER studies as “trials”. “None of the data you have shown are from trials,” the audience member observed. “You need to be careful about terminology and you need to be careful about head-to-head comparisons,” based on non-randomised, observational data, a point conceded by Stoner.
Another commenter from the floor challenged both Stoner and Metzger to offer the situation in which they go against the grain and, respectively, proceed with transfemoral CAS in the case of the former and with CEA in the case of the latter. “Transfemoral versus TCAR? Based on the common carotid artery, I do think you can cheat somewhat on the length, but you can’t cheat on the quality of artery,” Stoner responded.
