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Carotid Artery Stenting Where do we stand in 2013?

Carotid Artery Stenting Where do we stand in 2013?. Chong Tze Tec MBBS FACS Consultant Vascular and Endovascular Surgeon Singapore General Hospital Adjunct Assistant Professor of Surgery Duke NUS Medical School. Stroke. 3 rd leading cause of death in US

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Carotid Artery Stenting Where do we stand in 2013?

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  1. Carotid Artery StentingWhere do we stand in 2013? Chong Tze Tec MBBS FACS Consultant Vascular and Endovascular Surgeon Singapore General Hospital Adjunct Assistant Professor of Surgery Duke NUS Medical School

  2. Stroke • 3rd leading cause of death in US • 750 000 people will have a stroke this year • 160 000 will die from it • 15-30% become permanently disabled • 20-30% caused by extracranial carotid disease

  3. Carotid endarterectomy • Carotid artery stenting • Unresolved issues

  4. Carotid Endarterectomy Procedures

  5. CEA: Large-Scale Randomized Trials • ECST (1991) • NASCET (1991) • VA Asymptomatic Study (1993) • ACAS (1995) • ACST (2004)

  6. NASCET 26% vs 9% rate at 2 years Barnett HJM et al NEJM 1998;339:1415-1425

  7. ACAS 11% vs 5.1% rate at 5 years; p=.004 ACAS Investigators JAMA 1995;273:1421

  8. Curves cross at 3 years Curves cross at 1.5 years

  9. ACST

  10. Results

  11. Carotid Artery Stenting

  12. Carotid Stenting- Indications • Carotid restenosis • Anatomically difficult lesion (e.g. above C2) • Radiation-induced disease • “High-risk” patients - Consensus Conference, Montefiore Vascular Symposium 2001

  13. Anatomic/technical Inaccessible lesion Hostile neck Radiation disease Restenotic lesion Comorbidities Age>80 CHF Recent coronary event or procedure COPD Contralateral occlusion Renal failure “High Risk” criteria for CEA ?

  14. CEA vs CAS: Major RCTs • CAVATAS (Lancet 2001) • SAPPHIRE (NEJM 2004) • SPACE (Lancet 2006) • EVA-3S (NEJM 2006) • CREST (2010) • ICSS (2009)

  15. SAPPHIRE

  16. SAPPHIRE Primary endpoints • Death/stroke/MI within 30 days • Death/ipsilateral stroke between 31 days and 1 year 747 patients were enrolled in the study and 334 patients underwent randomization. Of those not randomized, 406 entered into a stent registry and 7 entered a surgical registry

  17. SAPPHIRE results

  18. SAPPHIRE Discussion • CAS is not inferior to CEA in high risk patients based on 1 year data • Trial was terminated early due to the establishment of nonrandomized stent registries

  19. SPACEStent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy

  20. SPACE Hypothesis • CAS is not inferior to CEA for the treatment of severe symptomatic carotid stenosis

  21. SPACE results

  22. SPACE Discussion • SPACE failed to prove the non-inferiority of CAS compared to CEA • 30d stroke/death rate was 6.84% for CAS versus 6.34% for CEA • CEA 30d event rates are similar to NASCET (6.5%)

  23. SPACE – Follow up

  24. SPACE – Follow up results

  25. SPACE – Follow up results • Recurrent restenosis >70% was higher in the CAS group compared to the CEA group at 2 years • 10.7% vs 4.6%, p=0.0009

  26. EVA-3S

  27. EVA-3S: Results at 30 days

  28. EVA-3S – Follow up

  29. EVA-3S – Follow up results • Cumulative probability of periprocedural stroke or death and non-procedural ipsilateral stroke at 4 years

  30. CAS vs CEA trials • Failed to show benefit so far • Perhaps there are subtleties involved which are underappreciated • Lesion characteristics • Technical aspects to CAS • Operator experience

  31. Confounding issues • Arch anatomy • Stents design • Embolic protection devices • Plaque evaluation

  32. Open cell vs Closed cell stents

  33. Open cell stents are more conformable therefore offer better wall apposition and are more flexible and trackable

  34. Cerebral embolization, as detected by TCD and DW-MRI, occurs with similar frequency After CAS with open-cell and closed-cell stents… does not support the superiority of any stent design with respect to cerebral embolization

  35. Cerebral Protection Devices

  36. Difficult Anatomies for Distal Protection

  37. MOMA device

  38. Gore Flow Reversal System

  39. Embolic protection

  40. Asymptomatic lesions (n=36) • Diffusion weighted MRI at 24h post procedure • Average number of hits 6.1 vs 6.2 • Filter group did not show reduction in microemboli

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