Optimal Treatment of the ‘High-Risk’ Patient with Carotid Artery Stenosis

Four landmark randomized trials have clearly validated the use of carotid endarterectomy (CEA) for the management of asymptomatic and symptomatic significant carotid artery stenosis. However, its risk-to-benefit ratio is variable for different patients. With the advent of carotid artery stenting (CAS) and the recent improvements in medical therapy, an added degree of complexity has emerged in the effort to optimize management for patients with carotid artery disease. Patients with unfavorable anatomical features or medical comorbidities are generally considered a ‘high-risk group’ for surgical CEA. For these patients, minimal invasive CAS is often proposed as an alternative, preferential treatment. Over the past years, CAS is increasingly performed in these patients, particularly, since the Centers for Medicare and Medicaid Services (CMS) approved reimbursement for patients who met certain high-risk criteria for CEA. In this thesis we investigated outcome of patients with anatomic high-risk comorbid conditions undergoing CEA or CAS, ultimately enabling optimal decision making for the individual patient. Our results indicate that some, but not all, CMS high-risk criteria identified patients at increased risk for 30-day stroke or death after CEA. For both treatment modalities, symptom status was a significant predictor of adverse outcome. Of the high-risk criteria, congestive heart failure class III/IV, left ventricle ejection fraction