CQC Amit Gossain

72 yo male presenting for follow up physical exam PMHx: CAD HL DM Medications: Vytorin HCTZ Amlodipine Metformin

Physical Exam General: NAD HEENT: PERRL, NCAT, CV: +S1, +S2 RRR no m/g/r or JVD +carotid bruits Lungs: CTA no r/r/w Abd: soft, NTND, no organomegaly Extremities: no c/c/e

What’s the next step? Cerebral angiography Carotid duplex ultrasound Magnetic resonance angiography Computed tomographic angiography

Clinical Question In what cases is a carotid angioplasty and stent better than carotid endartectomy (CEA)

Indications CEA Symptomatic disease Asymptomatic disease TIA, Amaurosis fugax Asymptomatic disease For stenosis of 60-99%

Decisions 72 yo male with PMHx of HL, HTN, DM. asymptomatic 80% stenosis on ultrasound 54 yo male with PMHx of CAD with recent history of TIAs and 60% stenosis on ultrasound 84 yo male with PMHx of COPD, CAD, DM with bilateral carotid stenosis of 70%.

EVA-3S Hypothesis: CAS not inferior to CEA for treatment of severe symptomatic carotid stenosis. Exclusion Criteria: - high-risk patients with unstable angina, uncontrolled DM, uncontrolled HTN, previous carotid revascularization Mas JL et al, “Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial” Lancet Neurol. 2008 Oct;7(10):885-92. Epub 2008 Sep 5.

Criticism: - lack of experience by the interventionalists - prerequisite was two stent procedures with any new device - embolic protection for patients was optional early in trial - those treated with embolic protection were significantly lower (7.9 vs. 25%!)

SPACE: The Final Frontier Hypothesis: CAS not inferior to CEA for treatment of severe symptomatic carotid stenosis Eckstein HH, et al. “Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial.” Lancet Neurol. 2008 Oct;7(10):893-902. Epub 2008 Sep 5.

Criticism: - embolic protection devices with stenting was optional (although no significant difference in primary outcomes)

SAPPHIRE trial Hypothesis: CAS is not inferior to CEA in patients with either symptomatic or asymptomatic carotid stenosis who are considered high risk for surgery Yadav JS, et al. “Protected carotid-artery stenting versus endarterectomy in high-risk patients.” NEJM 2004 Oct 7; 351(15):1493-501

- bias towards CAS due to high number of patients with recurrent CAS Criticism: - bias towards CAS due to high number of patients with recurrent CAS - complication rates higher with repeat/redo CEA due to higher rates of embolization - high incidence of MI in perioperative period in CEA

Cases Revisited 72 yo male with PMHx of HL, HTN, DM. asymptomatic 80% stenosis on ultrasound 54 yo male with PMHx of CAD with recent history of TIAs and 60% stenosis on ultrasound 84 yo male with PMHx of COPD, CAD, DM with bilateral carotid stenosis of 70%.

Conclusions No study has appropriately defined roles of CAS vs CEA American Heart Association AND American Stroke Association made statements saying more definitive evidence needed for CAS. Gold Standard still CEA, BUT CAS has a role CAS not inferior in patients that are “high risk” (SAPPHIRE trial) CAS appears to be beneficial in younger populations (68yrs and younger)