Background Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence.Methods ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362.

Biochemical markers measurements of brain damage combined with neuropsychometric tests and DW-MRI can be used to evaluate silent injuries after CAS. The mechanisms of rise in S100beta and NSE levels at 24 hours after CAS may be due to increased perioperative microembolization rather than to hypoperfusion. Further studies are required to assess the clinical significance of those tests in carotid revascularization.

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The incidence of cardiac morbidity and mortality in patients who undergo carotid surgery ranges from 0.7% to 7.1%, but it still represents almost 50% of all perioperative complications. Because no data are available in literature about the impact of the anesthetic technique on such complications, a prospective randomized monocentric study was undertaken to evaluate the role of local anesthesia (LA) and general anesthesia (GA) on cardiac outcome. Methods: From November 1995 to February 1998, 107 patients were classified by the cardiologist as cardiac patients (IHD; history of myocardial infarction, previous myocardial revascularization procedures, or myocardial ischemia documented by means of positive electrocardiogram [ECG] stress test results) or noncardiac patients (NIHD; no history of chest pain or negative results for an ECG stress test). The patients were operated on after the randomization for the type of anesthesia (general or local). Continuous computerized 12-lead ECG was performed during the operative procedure and 24 hours postoperatively. The end points of the study were ECG modifications (upsloping or downsloping more than 2 mm) of the sinus tachycardia (ST) segment. Results: Fifty-five patients were classified as IHD, and 52 were classified as NIHD.Twenty-seven of the 55 IHD patients (49%) and 24 of 52 NIHD patients (46%) were operated on under GA. Thirty-six episodes of myocardial ischemia occurred in 22 patients (20.5%). Episodes were slightly more frequent (58%) and longer in the postoperative period (intraoperative, 10 ± 5 min; postoperative, 60 ± 45 min; P < .001). As expected, the prevalence of myocardial ischemia was higher in the group of cardiac patients than in noncardiac group (15 of 55 patients [27%] vs 7 of 52 patients [13%]; P < .02). By comparing the two anesthetic techniques in the overall population, we found a similar prevalence of patients who had myocardial ischemia (GA, 12 of 52 [23%]; LA, 10 of 55 [18%]; P = not significant) and a similar number of ischemic episodes per patient (GA, 1.5 ± 0.4; LA, 1.8 ± 0.6; P = not significant). Episodes of myocardial ischemia were similarly distributed in intraoperative and postoperative periods in both groups. It is relevant that under GA, IHD patients represent most of the population who suffered myocardial ischemia (83%). On the contrary, in the group of patients operated on under LA, the prevalence was equally distributed in the two subpopulations. Conclusion:The results confirm the different hemodynamic impact of the two anesthetic techniques. Patients who received LA had a rate of myocardial ischemia that was half that of patients who had GA. The small number of cardiac complications do not permit us to make any definitive conclusion on the impact of the two anesthetic techniques on early cardiac morbidity, but the relationship between perioperative ischemic burden and major cardiac events suggests that LA can be used safely, even in high-risk patients undergoing carotid endarterectomy.