1. Stents implantation to treat carotid lesions Lessons learned in the last 17 years Hugo Londero MD Córdoba-Argentina

2. Stents implantation to treat carotid lesions Lessons learned in the last 17 years: The weight of evidence What can we do to obtain better results Increase Team Experience Deep patient evaluation before intervention Differences in high surgical and endovascular risk Technical advances New stents designs Cerebral protection

3. Carotid Artery Stenting vs Carotid Endarterectomy Meta-analysis and Diversity-Adjusted Trial Sequential Analysis of Randomized Trials – Bangalore S et al. Arch Neurol. Published online October 11, 2010 Study Periprocedural death, myocardial infarction or stroke

4. Short term ORs for Stroke Carotid Artery Stenting vs Carotid Endarterectomy: A comprehensive Meta-analysis of Short-Term and Long-Term Outcomes Economopoulos K et al. Stroke (pusblished on line, January 13, 2011)

5. Carotid Artery Stenting vs Carotid Endarterectomy: A comprehensive Meta-analysis of Short-Term and Long-Term Outcomes Economopoulos K et al. Stroke (published on line, January 13, 2011) : Short term ORs for Death or Stroke

6. Carotid Artery Stenting vs Carotid Endarterectomy: A comprehensive Meta-analysis of Short-Term and Long-Term Outcomes Economopoulos K et al. Stroke (pusblished online, January 13, 2011) : Short term ORs for Myocardial Infarction

7. : Short term ORs for cranial nerve injury Carotid Artery Stenting vs Carotid Endarterectomy: A comprehensive Meta-analysis of Short-Term and Long-Term Outcomes Economopoulos K et al. Stroke pusblished online Jan 13, 2011

8. Carotid Artery Stenting vs Carotid Endarterectomy Meta-analysis and Diversity-Adjusted Trial Sequential Analysis of Randomized Trials – Bangalore S et al. Arch Neurol. Published online October 11, 2010 Intermediate to long term death or any stroke

9. Initial Comments: Two updated meta-analysis found CEA to be superior to CAS for death, stroke and AMI incidence for short term outcomes The incidence of stroke and death was greater for CAS, however myocardial infarction and cranial nerve injuries were more frequent with CEA There were not differences in the incidence of death and stroke at intermediate to long term outcome

10. CREST Trial – Stenting versus Endarterectomy for Treatment of Carotid Artery Stenosis (N Engl J Med 2010; 363:11-23) P=0.38P=0.51 )

11. CREST Trial – Stenting versus Endarterectomy for Treatment of Carotid Artery Stenosis (N Engl J Med 2010; 363:11-23)

13. (JACC 2011;Vol 57, N o XX)

14. Carotid Artery Stenting Fundación Favaloro(Buenos Aires) October ’95 - December ’00 Sanatorio Allende(Córdoba) December ’97/December‘12-FLENI (BsAs)

15. Conclusion I: * CAS could be considerer and alternative to CEA in Symptomatic patients with lesions ≥50% * Probably could be beneficial in Asymptomatic patients with lesions ≥ 80% or other high risk characteristics. * It is necessary a rigorous selection of patients to avoid high risk CAS patients * CAS technique is highly operator (skill and experience) dependent

16. Stents implantation to treat carotid lesions Lessons learned in the last 17 years: The weight of evidence What can we do to obtain better results Increase Team Experience Deep patient evaluation before intervention Differences in high surgical and endovascular risk Technical advances New stents designs Cerebral protection

17. Systematic review of the perioperative risks of stroke or death after Carotid angioplasty and stenting. (Touzé E et al. Stoke 2009;40(12)e:683-93) 57.713 patients, 206 papers (13 randomized-193 registries)

18. Pro CAS Registry, Theiss W, Mathias K 2008

19. Stroke and Death decrease during CREST trial inclusion period

20. Stents implantation to treat carotid lesions Lessons learned in the last 17 years: The weight of evidence What can we do to obtain better results Increase Team Experience Deep patient evaluation before intervention Differences in high surgical and endovascular risk Technical advances New stents designs Cerebral protection

21. Duplex Scan: Functional evaluation Plaque composition Angio MRI-Gadolinium enhanced Multi Slice angio CT Intracraneal artery reconstruction Cerebral CT & MRI Neurological examination

22. Stents implantation to treat carotid lesions Lessons learned in the last 17 years: The weight of evidence What can we do to obtain better results Increase Team Experience Deep patient evaluation before intervention Differences in high surgical and endovascular risk Technical advances New stents designs Cerebral protection

23. High CEA Risk = / High CAS Risk

24. CAS: High risk patients : Distorted Aortic Arch Aortic Arch atherosclerosis and calcification Elongated and tortuous carotids Intra thoracic ostial lesions

25. High Risk CAS : Common or Internal Carotid anomalies

26. Difficult Carotid Angioplasty: Very Old patients N=174n=390n=594n=145

27. Conclusions Complex Carotid Angioplasty definition include a number of anatomic, angiographic and/or clinical conditions that increase de difficulty and risk of the procedure. In this situation special skills of the operator and a greater device inventory is needed to reduce complications. Complexity do not exclude the endovascular treatment, however, its recognition allows better risk estimation and comparison with other therapeutic options in order to select the best one.

28. Stents implantation to treat carotid lesions Lessons learned in the last 17 years: The weight of evidence What can we do to obtain better results Increase Team Experience Deep patient evaluation before intervention Differences in high surgical and endovascular risk Technical advances New stents designs Cerebral protection

29. Difficult Carotid Angioplasty: Distorted Aortic Arch Telescopic Catheter and Wire to facilitate the wire progression Catheter push and force vectors

30. Difficult Carotid Angioplasty: Distorted Aortic Arch Radial or Brachial Approach

31. Difficult Carotid Angioplasty: Diffuse disease Mother and child to direct advance the catheter over the wire

32. Stents implantation to treat carotid lesions Lessons learned in the last 17 years: The weight of evidence What can we do to obtain better results Increase Team Experience Deep patient evaluation before intervention Differences in high surgical and endovascular risk Technical advances New stents designs Cerebral protection

33. Belgian, Italian Carotid (BIC) Study CIRSE 2006

34. Stainless steal mesh-Wallstent-Boston Sci. Hybrid Carotid Stent – Cristallo-Invatec-Medtronic

35. Stents implantation to treat carotid lesions Lessons learned in the last 17 years: The weight of evidence What can we do to obtain better results Increase Team Experience Deep patient evaluation before intervention Differences in high surgical and endovascular risk Technical advances New stents designs Cerebral protection

36. P (no inf.)= 0.09 0,66 Early Outcome of Carotid Angioplasty and Stenting With and Without Cerebral Protection: A Systematic Review of the Literature Kastrup A et al. Stroke 2003; 34:813-19 P 0.0010.0010.05 2357 pac. SIN Protección – 839 pac.CON protección

37. Sistemas de Protección Cerebral

38. Proximal Occlusion: thrombotic lesion

39. The PROFI Study (Prevention of Cerebral Embolization by Proximal balloon Occlusion Compared to Filter Protection During Carotid Artery Stenting): A Prospective Randomize Trial. Bijuklic K et al. JACC published on line Jan 25,2012 Incidence of New Ischemic Lesions in Patients with Filter Protection versus Proximal Balloon Occlusion 87.1% 45.2%

40. Carotid Artery Stenting Fundación Favaloro October ’95 - December ’00 - Sanatorio Allende December ’97/December‘12-FLENI (BsAs) Global experience(October 1995/December 2012) Last 2 years (November 2010-December 2012)

41. F inal Conclusions: CAS could be considerer an alternative to CAE in symptomatic patients with lesions ≥ 50% or asymptomatics patients with lesions ≥ 80%. The crew must show results comparable to surgery. A deep patient evaluation before intervention is mandatory CAS risk is related to anatomical, biological and pathophysiologic factors different to those that determine the surgical risk New technical tricks simplifies the procedure and increase the safety Closed stents designs increase the coverage and diminish late distal embolization Proximal occlusive protection devices seem to be more efectives

42. THANK YOU VERY MUCH