it does not matter.”

1. it does not matter.” He added: “CREST has shown that the results are very compara-ble. The remaining differences are so small, that they are not relevant for individual patients.” Professor Sievert has experi-enced increasing levels of success with CAS. “Our results are getting better and better since we started using proximal protection in all pa-tients,” he said. “Our stroke rate is less than 1%, with zero procedural strokes.” CAS is an important treat-ment option in carotid stenosis, continued Professor Sievert, but ultimately the decision should rest with patients. “It should be valued as alternative to surgery,” he said. “Patients should have the final decision after informed consent.” Professor Storck also agreed that patients should be given the choice: “It should not be that stenting should be first line therapy in carotid stenosis,” he said, add-ing: “From the available studies, we cannot conclude that stenting is better.” Professor Storck also empha-sised the need for prospective trials and robust recording of data. “We need a quality assessment no matter which therapy we use – an honest assessment in order to avoid any harm to the patient. And this can be done through studies or registries.” Will ACST-2 change the game? For Carlo Setacci (Siena, Italy), who also spoke during the session, the debate of CAE versus CAS may be silenced thanks to results from the second Asymptomatic Carotid Sur-gery Trial (ACST-2) – a world-wide stroke prevention study compar-ing CEA and CAS in patients with asymptomatic carotid stenosis in whom there is substantial uncer-tainty as to which treatment is more appropriate.2 The trial has been tasked with comparing the two procedures in stroke prevention with long term follow up of patient from over 26 countries for at least five years. “I have been a keen supporter of ca-rotid artery stenting since the early 2000s,” Professor Setacci told LINC Review.”In my centre I started a carotid artery stenting programme in 2001, and up to now we have treated almost 3000 patients by carotid stenting. So I am a clear supporter of stenting, and I am really happy about the new interim results by ACST-2. “This trial is the largest trial ever conducted to compare stenting and endarterectomy in asympto-matic patients. One of the major points we know is that we cannot enrol patients when we don’t know exactly which procedure is better, so when we are uncertain about what to do we can enrol patients in this trial.” Early, blinded results from the trial have shown “outstanding” outcomes, Professor Setacci under-lined, with as low as 1% complica-tion rates/death. “We know that this data is even better than data from ACST-1, for carotid endarter-ectomy: it was 1.7% at that time for stroke and death,” he said. Referring to the notion of a game-changing shift in the use of carotid stenting in routine treat-ment, Professor Setacci stressed that ACST-2 has highlighted the importance of better skill sets and operator volumes in improv-ing outcomes. “We published a consensus in Italy in 2006 suggest-ing that to be considered ‘skilled operators’ for carotid stenting, you need a large number of procedures during your training (at least 75 carotid procedures during a two-year fellowship),” he said. “And then just to maintain your technical skill, you need to perform 50 stenting procedures per year. Continued on page 24 “We hope to encourage [a] learning curve for both procedures.” Carlo Setacci (Siena, Italy)

2. Continued from page 23 With this training, we are now able to offer patients stenting with a lower risk.” He added: “We need very skilled operators, and we have that now in ACST-2. We have this kind of experience because we know the track record required to enrol patients in this trial. And with this kind of experience we can change the game.” With this in mind, does Profes- sor Setacci feel that stenting will replace endarterectomy in common practice? “I don’t think anybody will ever throw carotid endarterectomy away,” he said. “I’m a surgeon so I clearly also believe in endarterectomy. But if we have people who can be very skilled in both procedures – along-side a centre that mixes together neurologists, vascular surgeons and stenting interventionalists – both carotid endarterectomy and carotid stenting have a safe and effective role to play.” For smaller, less-experienced centres, Professor Setacci sug-gested that one way to try and ensure better results was to more effectively train and prepare younger vascular surgeons to work with both CAS and CEA proce-dures. “We hope to encourage this learning curve for both proce-dures,” he said. “I know it won’t be easy but this is our primary aim as directors of our training school in vascular surgery.” Vascular surgery perspectives As a vascular surgeon who performs high volumes of either CEA or CAS intervention, Ramon Varcoe (Sydney, Australia) offered an unbiased account of when each therapy would be appropriate for use in his experience. He began by presenting his decision-making algorithm (Figure Figure 1 – Dr Varcoe’s decision-making algorithm for CEA or CAS indication “Both [CAS and CAE] treatments are excellent... but the truth is every patient is different.” Ramon Varcoe (Sydney, Australia) 24