Symptomatic carotid stenosis

Introduction
Carotid stenosis

Mild carotid stenosis (or plaque) with ESUS
In a secondary analysis of data from the NAVIGATE ESUS trial, there was no difference in ischemic stroke recurrence between rivaroxaban and aspirin treated patients. Rates of major bleeding were higher in the rivaroxaban arm than in the aspirin arm. Thus there is no real utility to using rivaroxaban in this setting.

The Carotid Revascularization Endarterectomy vs. Stenting trial (CREST, 2010 with follow-up in 2016)
This trial randomized symptomatic patients with carotid stenosis of ≥50% on angiography, ≥70% on ultrasonography, or ≥70% on CTA/MRA if 50-69% on ultrasonography to either carotid endarterectomy (CEA) or carotid artery stenting CAS). Symptomatic was defined as a TIA or minor stroke involving the ipsilateral carotid artery within 180 days prior to randomization). They subsequently included patients with asymptomatic carotid stenosis of ≥60% on angiography, ≥70% on ultrasonography, or ≥80% on CTA/MRA if 50-69% on ultrasonography. 2502 patients were randomized. The incidence of stroke was higher in the CAS group (4.1%) vs the CEA group (2.3 %) for a HR of 1.79 (95% CI 1.14 to 2.82). In contrast, the incidence of myocardial infarction (MI) was lower in the CAS group (1.1%) vs. the CEA group (2.3%) for a HR of 0.50 (95%C CI 0.26 to 0.94). The primary endpoint of any periprocedural stroke, MI, death, or postprocedural ipsilateral stroke was not different between the two groups. At 10 year follow-up there remained no difference in the primary endpoint, but there continued to be a higher risk of stroke or periprocedural death at 10 years (11.0% vs 7.9%, HR 1.37 with 95% CI 1.01 to 1.86). Long-term stroke incidence was not significantly different, with all of the data suggesting that periprocedural stroke incidence with CAS was the problem, and that otherwise it was likely as durable a treatment as CEA.