The ACST-1 and ACST-2 trials addressed carotid intervention in asymptomatic carotid stenosis. According to ACST-2 (2021), stenting versus endarterectomy for asymptomatic stenosis showed:
- A Similar rates of periprocedural stroke/death and similar 5-year ipsilateral stroke rates between CEA and CAS ✓
- B Significantly higher periprocedural stroke rate with CAS compared to CEA
- C CAS eliminated the need for antiplatelet therapy post-procedure
- D CEA had higher 5-year ipsilateral stroke rates than CAS
Explanation
The ACST-2 trial (2021, NEJM) directly compared carotid artery stenting (CAS) vs CEA in 3,625 patients with asymptomatic severe carotid stenosis. It found similar rates of any stroke or death within 30 days (2.2% CAS vs 1.4% CEA, not significant with wide confidence intervals) and similar 5-year ipsilateral stroke rates (~2.5% each). The key conclusion is that in experienced centres, CAS and CEA have broadly equivalent safety and efficacy for asymptomatic stenosis, allowing individualized selection based on anatomical and patient factors. Both require dual antiplatelet therapy post-procedure.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.