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Stroke is the fifth1 leading cause of death in the United States and represents the single most important cause of long-term physical and intellectual disability. Each year in the United States, approximately 795,000 people experience a new or recurrent stroke (87% ischemic, 13% hemorrhagic), and roughly 610,000 (75%) of these strokes are first events. On average, every 40 seconds someone in the United States experiences a stroke; there are close to 130,000 annual deaths related to stroke, and the cost of managing stroke patients in the United States in 2012 was approxinately $33 billion.1 Unfortunately, despite important advances and progress in several areas of medicine, the treatment options for an established stroke are limited and the expectation for reversibility or improvement of stroke-related neurological deficits is both guarded and unpredictable.

Extracranial (cervical) carotid disease (“carotid stenosis”) is responsible for up to 20% of strokes2,3 and the intent of treatment for carotid stenosis (medical, surgical, or stenting) is to prevent a future ipsilateral stroke. In the past, carotid artery stenting (CAS) was considered to be investigational or experimental and outcomes of this new procedure were constantly compared and benchmarked with the outcomes of carotid endarterectomy (CEA), long considered the gold standard for treatment of carotid stenosis. The results of three large prospective multicenter randomized trials with head-to-head comparisons of CAS and CEA are now available4,5,6,7,8,9 and provide Level 1 evidence to support treatment recommendations in both symtpomatic and asymptomatic patients (Table 95–1). Although the US Food and Drug Administration (FDA) provided regulatory device approvals for CAS in high surgical risk and standard surgical risk patients in 2004 and 2011, respectively,10 as of 2016, the Centers for Medicare and Medicaid Services (CMS) only reimburse CAS when the procedure is performed in symptomatic patients with > 70% stenosis and who are at high risk for CEA.

TABLE 95–1.Key Features of the Three Largest Randomized Trials Comparing Carotid Artery Stenting and Carotid Endarterectomy

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