A 68-year-old man with an 80% asymptomatic stenosis of the right internal carotid artery is evaluated for intervention. According to the ACST-2 trial (published 2021), what was the major finding comparing carotid endarterectomy (CEA) versus carotid artery stenting (CAS)?

• A CEA had significantly lower stroke and death rates than CAS
• B CAS had significantly lower stroke and death rates than CEA
• C Medical management alone is superior to both CEA and CAS
• D CEA and CAS had similar rates of non-procedural stroke at 5 years in asymptomatic stenosis ✓

Explanation

The ACST-2 trial (2021), the largest randomized trial comparing CEA vs CAS for asymptomatic carotid stenosis, found that both procedures had similar 5-year rates of non-procedural stroke (2.5% vs 2.5%). There was a non-significant trend toward higher procedural risk with CAS compared to CEA. The key message is that for appropriately selected patients with significant asymptomatic carotid stenosis, both techniques achieve similar long-term stroke prevention. Patient selection, operator experience, and anatomical suitability guide the choice between CEA and CAS.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.