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In this issue of JNIS (see page 59), Claus et al present a series of 190 consecutive carotid artery stents (CASs) performed by a single experienced operator using a single carotid stenting system with a 6.8% 30-day stroke and death rate.1 A large number of the patients were symptomatic (55%). If one assumes a 30-day stroke and death rate for carotid endarterectomy (CEA) of 6% for symptomatic patients and 3% for asymptomatic patients,2–7 setting aside the fact that some of the patients may have been higher than normal risk for CEA, one would have expected a 30-day event rate of 4.7% for CEA in this population. Claus et al did not observe a difference between the symptomatic and asymptomatic patients, which is different from most reported series including both groups of patients.8–12 The authors arrive at two conclusions: first, that the results are better than many reported series because of close postprocedure monitoring, and second, that CAS is not recommended for asymptomatic patients because the complication rate is unacceptably high.
The first conclusion, that CAS patients should be monitored closely after the procedure in a setting where parameters like blood pressure, heart rate and blood glucose can be best controlled is not controversial; I do not know anyone who would disagree. As for the second conclusion, that CAS should not be performed in asymptomatic patients, that remains to be seen. I think CAS can be done with a lower complication rate than reported here.
I have no doubt that the skill of the operator is the most important determinant of the outcome with carotid stenting. A prominent neurologist remarked to me recently, ‘If you want to play the piano well you have to …