To the Editor: Carotid stenting is a new application of endovascular therapy. Its efficacy in preventing strokes is yet to be established, by contrast with the proven Level 1 evidence of benefit from carotid endarterectomy.

The risks of implanting carotid stents at present appear greater than the risks of carotid endarterectomy. An overview of carotid endarterectomies in Australia is maintained by vascular surgeons, through audits such as the ongoing Melbourne Vascular Surgeons Association Audit and the New South Wales Carotid Endarterectomy Audit. The technique of carotid stenting, the stents themselves and the brain-protective devices used during the implanting of stents are expensive and still evolving. The long-term durability of stents is unknown.

Australian vascular surgeons, neuroradiologists and neurologists are awaiting the outcome of two major international randomised trials of carotid stenting versus endarterectomy (the US Carotid Revascularization Endarterectomy versus Stent Trial and the European International Carotid Stenting Study). These seek Level 1 evidence of the comparative risks and success of the new stenting procedures in stroke prevention and aim to document the late outcome of stenting, particularly the incidence of restenosis, which is a significant problem in other arteries after stenting.

While these definitive trials are in progress, vascular surgeons of the Royal Australasian College of Surgeons wish to add their note of caution to the reservations expressed in the NHMRC guidelines on stroke prevention1 and the recommendations of the Australian Association of Neurologists.2 A recent commentary by Spence and Eliasziw3 illustrates the disparate nature and the limitations of existing studies of carotid stenting.

We consider carotid stenting is not yet appropriate for widespread use in Australia. Experienced endovascular and neurology teams should continue to evaluate the new procedure. Stenting of symptomatic carotid atheroma should only be conducted with the consent of patients who are fully informed about stenting's known hazards and unproven status and who understand that the established treatment is carotid endarterectomy.4 Clinicians should audit closely the immediate outcome and long-term complications of any carotid stenting they perform.