I appreciate Dr. Abbott’s comments about carotid artery angioplasty and stenting (CAS) from our review article on Interventional Neuroradiology.

I agree with her opinion that only a small percentage of asymptomatic patients, likely less than 5%, may benefit from a carotid intervention. I agree that in the major randomized controlled trials (RCTs) of CAS versus carotid endarterectomy (CEA), stenting was associated with a higher risk of periprocedural stroke.^{Reference Ederle, Dobson and Featherstone1,Reference Brott, Hobson and Howard2} Finally, I agree that the high-risk features of carotid plaque in asymptomatic patients have not been adequately evaluated in the context of current optimal medical management (OMT).

I do, however, take issue with her statement that “there is no proven indication for any carotid artery procedure compared to current standards of medical intervention, only evidence of harm and cost”. Dr. Abbott does not reference this declaration, and the evidence for such a policy is suggestive at best.^{Reference Chaturvedi and Rothwell3} The most current Cochrane review^{Reference Rerkasem, Orrapin, Howard and Rerkasem4} still regards CEA as highly beneficial for stroke reduction in symptomatic patients with 70%–99% stenosis, and of some benefit for those with 50%–69% stenosis. The efficacies of both CEA and CAS compared to current OMT in symptomatic and asymptomatic patients are being evaluated in the ECST-2 and ACST-2 trials,^{Reference Zhu and Yu5} with the ECST-2 results expected in 2022. Until definitive RCT data is available, carotid revascularization for severe, symptomatic stenosis remains the gold standard.