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.

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Symptomatic occlusion of the initial section of the subclavian artery, resistant to intravascular treatment, is an indication for a surgery as it exacerbates the verterbrobasilar insufficiency and creates the risk of peripheral embolism. Reconstructive surgery fixes the reversed blood flow in the vertebral artery, alleviates neurological and limb ischemia symptoms. the aim of the study was to retrospectively evaluate the results of surgical treatment of the occlusion of the initial section of the subclavian artery using transposition or subclavian-carotid by-pass with a PTFE. material and methods. Retrospective analysis covered 55 patients operated on between June 1996 and August 2008 for occlusion of the left subclavian artery. 39 patients underwent a subclavian artery transposition (SCT) and the remaining 16 had a subclavian-carotid by-pass (SCB) using a PTFE. Indications for surgery included ischeamic symptoms in the upper limb and impaired vertebrobasilar circulation. Clinical symptoms occurred in the following order: vertebrobasilar insufficiency and upper limb ischemia (62%), upper limb ischemia symptoms (22%), vertebrobasilar insufficiency (16%). Results. There were no early deaths (by day 30). Ischemia was lifted in 100% of the patients operated using transposition and in 93% of those with a by-pass. In the perioperative period, one patient had a bypass thrombosis, and 2 patients had a transitional brain ischemia. These incidents affected patients who underwent subclavian-carotid by-pass. In the late postoperative period, 12 patients (21.81%) died due to cardiological complications and 7 patients (12.72%) for other causes, and none of them was related to the primary surgery. All patients with transposition have maintained the primary patency, with average follow-up period of 73 months . In the group with a by-pass, occlusion occurred in 3 patients in the first follow-up month. These incidents had no effect on survival rates. For the remaining 14/16 patients from the SCB group the average primary patency was 63.4 (8-104) months. conclusions. Subclavian-carotid transposition is a safe and effective method of upper limb revascularization. It is technically more difficult than the by-pass but ensures a better short-term and long-term result.