Surgical and endovascular interventions for the secondary prevention of stroke

Several different surgical and endovascular interventions are used in the secondary prevention of stroke, the most frequent of which is carotid endarterectomy. Endarterectomy is beneficial in patients with 50-99% recently symptomatic carotid stenosis. Recent research has gone further in identifying exactly which such patients are likely to benefit most from carotid endarterectomy and when the intervention is most effective. Individual risk modelling is useful in selecting patients for endarterectomy for symptomatic stenosis, although timely surgery and optimal medical treatment are of equal importance. Although data on comparative procedural risks outside randomized trials are difficult to interpret, the techniques involved in both carotid endarterectomy and stenting are evolving and continued audit of performance is essential. Ongoing randomized trials will determine whether or not the procedural risks of stroke and death are definitely lower with endarterectomy, but continued efforts to reduce the procedural risks of both approaches will still be important. The other key issue is how the procedural risks of stenting vary with patient characteristics-perhaps the most important question being not whether endarterectomy is better than stenting or vice versa, but for whom is one technique likely to be better than the other. © 2009 S. Karger AG, Basel. All rights reserved.