Additionally, a registry maintained by the Society for Vascular Surgery documented a 30-day postoperative combined rate of stroke and death of This rate among unselected surgeons was compa- rable to the rate seen among surgeons selected to participate in a trial. Endovascular Treatment for Asymptomatic Carotid Stenosis Carotid angioplasty and stenting (CAS) is being performed The Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial found that CAS was not inferior (within 3%; P=0.004) to endarterectomy (based on a composite out- come of stroke, MI, or death within 30 days or death result- ing from neurological cause or ipsilateral stroke between 31 and 365 days) in a group of patients considered to be at high risk for CEA.532 About 70% of the subjects had an asymptom- atic stenosis, with rates of stroke, MI, or death of 5.4% with stenting and 10.2% with endarterectomy (P=0.20) at 30 days. At 1 year, the composite end point occurred in 9.9% of the CAS patients and 21.5% of the CEA patients (P=0.02). Three- year outcomes from the SAPPHIRE trial showed that patients receiving CAS had a significantly higher death rate (20.0%) than stroke rate (10.1%),533 raising questions about the long- term value of the procedure in this high-risk cohort. In addi- tion, there was no medically treated control group, and the complication rates in both treatment arms were high enough to raise questions about the benefit of either intervention over medical therapy alone. Several industry-supported registries have reported peri- procedural complication rates of 2.1% to 8.3%.534 The lack of medically treated control groups makes the results of these registries difficult to interpret. 