Journal Review in Vascular Surgery: Carotid Revascularization – CEA, Stent or Nothing at All?

Behind The Knife: The Surgery Podcast

Science, Health & Fitness, Medicine, Education

4.8 • 1.4K Ratings

🗓️ 13 November 2025

⏱️ 43 minutes

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Summary

Carotid artery disease management has come a long way. From the days when every stroke meant an endarterectomy to a modern era defined by precision, evidence, and evolving technology. With advances in medical therapy and newer techniques like TCAR, the vascular surgeon has even more to consider when choosing the best treatment for carotid disease. Join us as we break down the major landmark trials NASCET, CREST and the Asymptomatic Carotid trials, and discuss how their findings shape our clinical decisions in practice today.

Hosts:
· Christian Hadeed -PGY 4 General Surgery, Brookdale Hospital Medical Center
· Paul Haser -Division Chief, Vascular Surgery, Brookdale Hospital Medical Center
· Andrew Harrington, Vascular surgery, Brookdale Hospital Medical Center
· Lucio Flores, Vascular surgery, Brookdale Hospital Medical Center

Learning Objectives:
· Review the key findings and clinical implications of the NASCET, ACST, and CREST trials.
· Discuss patient selection for carotid endarterectomy (CEA) vs carotid artery stenting (CAS).
· Understand how age, calcification, and aortic arch anatomy affect stenting outcomes or choice between stent and CEA.
· Identify how advances in medical therapy have influenced management of asymptomatic disease.
· Discuss appropriate screening/ follow up plans for patients who do not meet criteria for intervention

References:
- North American Symptomatic Carotid Endarterectomy Trial Collaborators. (1991). Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. The New England Journal of Medicine, 325(7), 445–453. https://pubmed.ncbi.nlm.nih.gov/1852179/
- Brott, T. G., Hobson, R. W. II, Howard, G., Roubin, G. S., Clark, W. M., Brooks, W., ... & Howard, V. J. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. The New England Journal of Medicine, 363(1), 11–23. https://pubmed.ncbi.nlm.nih.gov/20505173/
- Halliday, A., Mansfield, A., Marro, J., Peto, C., Peto, R., Potter, J., & Thomas, D.; MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. (2004). Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: Randomized controlled trial. The Lancet, 363(9420), 1491–1502. https://pubmed.ncbi.nlm.nih.gov/15135594/
- Halliday, A., Bulbulia, R., Bonati, L. H., Chester, J., Cradduck-Bamford, A., Peto, R., & Pan, H., & the ACST-2 Collaborative Group. (2021). Second asymptomatic carotid surgery trial (ACST-2): A randomised comparison of carotid artery stenting versus carotid endarterectomy. The Lancet, 398(10305), 1065-1073. https://doi.org/10.1016/S0140-6736(21)01910-3

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Transcript

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0:00.0	Behind the Night, the Surgery Podcast, relevant and engaging content designed another episode of Behind the Knife.
0:26.5	My name is Christian Hadid and today we will be discussing Karate disease.
0:30.4	We have four landmark trials to discuss and by the end of this you'll be better able to
0:34.5	answer the questions of who should get a carotid endartherectomy,
0:37.8	who should get a stent, and who should just be managed medically. To help us answer these
0:42.4	questions we have with us Dr. Flores, Dr. Hazer, and Dr. Harrington, from the Brookdale
0:47.3	Vascular Surgery team. With their different levels of experience, we'll not only examine
0:52.0	the landmark trials, but also how they apply the data in real-world
0:56.2	practice today. These studies gave us clear answers in some places and a lot of gray zones and
1:01.7	others. That's where our discussion is going to get interesting. Welcome, everyone.
1:06.4	Thanks for that warm. Welcome, Christian. We're excited to be here today. Before we dive into the papers,
1:12.0	I think it's helpful to prime everyone on carotid disease and how they should be thinking about the data.
1:18.5	When trying to decide what intervention is best for your patient, the key is to group patients into two
1:23.4	major categories, symptomatic or asymptomatic. Then break them down further by the degree
1:29.9	of credit stenosis, whether it's high grade, over 70%, moderate, 50 to 69%, or mild stenosis,
1:37.5	which is considered less than 50%. And of course, every patient's individual risk profile matters.
1:42.8	This framework helps us to group and interpret the data.
1:46.7	Yeah, so it's really about symptoms and then degrees of stenosis.
1:50.3	Thanks, Dr. Hazer.
1:51.3	That's a great way to kind of organize our thinking and quickly figure out which patients
1:55.0	will clearly benefit and those who clearly won't.
1:57.9	With that, let's dive into our first paper which showed that surgery is clearly
	...

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