A critical look at "High-Risk" in choosing the proper intervention for patients with carotid bifurcation disease

Refinements in the technique of carotid endarterectomy have been accompanied by a growing literature calling into question the notion that a broad class of patients is at high-risk for surgery due to clinical comorbidities. Moreover, progress in the percutaneous revascularization of carotid bifurcation disease has highlighted the need for direct comparisons between endarterectomy and stenting across the entire spectrum of perioperative risk. The improved safety of carotid stenting, to some extent due to the advent of cerebral protection devices, has further altered the risk-to-benefit analysis. Lastly, dramatic improvements in medical therapy for the systemic manifestations of atherosclerosis have prompted a reevaluation of carotid revascularization as the standard of care for patients with severe carotid bifurcation stenosis. Endarterectomy and stenting each have unique procedure-specific factors that determine whether a patient is at increased risk for perioperative complications. Determining which patients are at high-risk for these modalities will impact the individualized treatment algorithm. This article examines the anatomical and physiologic conditions that can affect the anticipated outcome of each treatment modality. Ultimately, a tailored approach to each patient's clinical situation is likely to result in the best outcome following treatment.