Stroke ranks as the third leading cause of death, behind diseases of the heart and cancer. It is also the most important cause of disability. Approximately 750,000 people experience a stroke annually, costing an estimated $40 billion in direct and indirect costs. Approximately 25% of these ischemic events are related to occlusive disease of the cervical internal carotid artery. Carotid atherovascular stenosis increases the risk of ischemic stroke by acting as an embolic source, and causing hypoperfusion of the ipsilateral cerebral hemisphere. With some limitations, the North American Symptomatic Carotid Endarterectomy Trial (NASCET), European Carotid Surgery Trialists' Collaborative Group (ECST), and Asymptomatic Carotid Atherosclerosis Study (ACAS) have shown that carotid endarterectomy (CEA) substantially reduces the risk of stroke associated with certain grades of carotid stenosis. During the past few years, carotid angioplasty and stenting (CAS) has evolved as an alternative to CEA, particulairly in patients who are known to have a higher complication rate with CEA.
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Multiple carotid stent registries are being maintained in the United States, and two randomized, controlled trials are currently under way: the Carotid Revascularization Endarterectomy versus Stent Trial (CREST), which is jointly sponsored by the National Institutes of Health and Guidant Corporation (Indianapolis, IN), and the Study of Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) supported by Cordis Corporation (Miami Lakes, FL). The results of these studies are expected to give the Level I evidence necessary for Food and Drug Administration-approval for CAS as an optimal technique for carotid revascularization.