1. Managing Carotid Disease after CREST – CEA: Still the Gold Standard
David H. Deaton, MD FACS
Chief, Vascular and Endovascular Surgery
Georgetown University Hospital / MedStar Vascular Institute
Washington, DC

2. Disclosures Aptus EndoSystems – Consultant ROX Medical – Consultant
M2S – Honoraria and consultant
Boston Scientific – Investigator for Clinical Trial
Vascutek / Terumo – Investigator for Clinical Trial

3. More disclosures I’m a big fan of endovascular techniques
My job title is “Chief of Endovascular”
I do more endovascular procedures than open procedures
I’m an “early adopter”, gadget lover
BUT
I do both open and endovascular
Inappropriate endovascular techniques harm future of all endovascular techniques
I HATE STROKES

4. Carotid: A Unique Circulatory “Habitat”
Large, high flow / low resistance vessel
Physiologic shape (carotid “bulb”) yields turbulence
Intimate association with baroreceptor

5. Carotid Lesions: Focal, Bulky, Heterogenous
Not a revascularization procedure.
An anti-embolic procedure.

6. Carotid Artery Stenosis
2.3 mm
9.8 mm

7. Medical / Surgical Stroke Risks
Hallett et al: Comprehensive Vascular and Endovascular Surgery © 2004

9. Meta-analysis of CAS trials: Randomized Controlled
Stroke & Death
Stroke
Clinical results of carotid artery stenting compared with carotid endarterectomy 
Soma Brahmanandam, Eric L. Ding, Michael S. Conte, Michael Belkin, Louis L. Nguyen
Journal of Vascular Surgery 
February 2008 (Vol. 47, Issue 2, Pages )

10. Meta-analysis of CAS trials: Symptomatic Patients
Stroke & Death
Stroke
Clinical results of carotid artery stenting compared with carotid endarterectomy 
Soma Brahmanandam, Eric L. Ding, Michael S. Conte, Michael Belkin, Louis L. Nguyen
Journal of Vascular Surgery 
February 2008 (Vol. 47, Issue 2, Pages )

12. Only 50 strokes in 1000 untreated patients

13. CEA vs. CAS: 2005 All U.S. Asymptomatic Patients
Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005 , 02 October 
James T. McPhee, Andres Schanzer, Louis M. Messina, Mohammad H. Eslami
Journal of Vascular Surgery 
December 2008 (Vol. 48, Issue 6, Pages e1)

14. CEA vs. CAS: 2005 All U.S. Symptomatic Patients
Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005 , 02 October 
James T. McPhee, Andres Schanzer, Louis M. Messina, Mohammad H. Eslami
Journal of Vascular Surgery 
December 2008 (Vol. 48, Issue 6, Pages e1)

15. Keeping Score The CREST Way Clinical vs. Chemical
Stroke was defined as an acute neurologic event with focal symptoms
and signs, lasting for 24 hours or more,
that were consistent with focal cerebral ischemia.
Myocardial infarction was defined by a creatine kinase MB or troponin level
that was twice the up-per limit of the normal range or higher according to the
center’s laboratory, in addition to either chest pain or symptoms consistent
with ischemia or ECG evidence of ischemia, including new ST- segment
depression or elevation of more than 1 mm in two or more contiguous
leads according to the core laboratory.

16. Gupta N, Corriere MA, Dodson TF, et al
Gupta N, Corriere MA, Dodson TF, et al.The incidence of microemboli to the brain is less with endarterectomy than with percutaneous revascularization with distal filters or flow reversal [In Process Citation]J Vasc Surg (United States), Feb 2011, 53(2) p316-22

17. Diffusion-weighted MRI 48 hours post procedure
J Vasc Surg 2011 in press
CAS in 29 men, 30 procedures
Diffusion-weighted MRI 48 hours post procedure
131 new lesions in 29 patients
90.8% cortical / subcortical
1 patient with “minor” stroke that resolved

18. “…quality-of-life analyses among survivors at 1 year in our trial
indicate that stroke had a greater adverse effect on a broad range
of health-status domains than did myocardial in- farction.”

19. “Essence” of all Carotid Therapy
A prophylactic procedure
Symptomatic pts. – Treat 5 to help 1
Asymptomatic pts. – Treat 20 to help 1
Control, Control, Control
Fewer operators doing more procedures
Control all elements of procedure

20. Elements that elevate risk in CAS
Failure to avoid arch angiography
Pre-procedure CT or MR arch and carotid characterization
Poor patient selection
Despecialization – more operators doing fewer procedures
Failure to minimize catheter manipulation
Failure to retreat in difficult cases
Failure of early and aggressive anticoagulation

21. Lessons from Surgical Evolution
CEA most “meticulous” of all vascular procedures
Small errors can have LARGE CONSEQUENCES
Most procedures easy, but efficacy of therapy dependent on 3-5% of all cases done
Patient selection critical
Non-invasive work-up has material contribution to overall results

22. Challenges for Future
Defining “high risk” surgical in your own environment
Recognizing and avoiding “high risk” stent patients
Refining patient selection in carotid stenting
Non-invasive
Plaque characteristics
“Virtual Intervention” planning prior to procedure (e.g. AAA virtual graft and pre-op imaging)
Defining the relative benefits of surgical and endovascular approaches in the low risk asymptomatic patient

23. “Where’s The Beef” More costly Longer hospitalization More ICU
More emboli during procedure
Increase in stroke over surgery
Short track record
Very low surgical complications
Clara Peller

24. Torture

25. My perspective
CAS is an important addition to therapeutic armamentarium for high risk patients
“High risk” is primarily anatomic
Tracheal stoma
Radiation
Post CEA restenosis
Current medical therapy may make debate “moot” in asymptomatic patients

26. Catching the “New Wave” in Endovascular Therapy
“It’s a Short Trip from Riding the Waves of Change to Being Torn Apart by the Jaws of Defeat.”

27. Thank you

28. A Few Caveats on “The Gold Standard”
CAS is surgery
We abandoned the “gold standard” in 1971
There are few established “standards” in the therapy of carotid disease

29. Stroke in the U.S. >700,000 strokes occur annually in the U.S.1
Stroke is the third leading cause of death with an estimated 164,000 deaths per year 1
Up to 30% of strokes are caused by carotid artery disease2
Stroke is the number 1 cause of disability in the U.S. 1
Health care costs for stroke in excess of $53.6 billion/year1
Over 50% of people under age 65 who have a stroke die within 8 years1
Older population with co-morbid disease1
1. Heart Disease and Stroke Statistics – 2004 Update, American Heart Association ACAS Executive Committee JAMA 273: , 1995

30. Stroke Incidence: Asymptomatic6 5 4 3 2 1
0-19%
20-29%
30-39%
40-49%
50-59%
60-69%
70-79%
80-89%
90-99%
Stroke Incidence (%)
Carotid Artery Stenosis
Asymptomatic Patients
Chambers New England Journal of Medicine. 315(14):860-5, 1986
Norris Stroke. 22(12): , 1991
Mendelsohn & Yadav, Management of Atherosclerotic Carotid Disease, Remedica Publishing, 2000

31. SVS Registry for CEA & CAS
1.5 years of data from “real world” practice
2818 patients with complete data
Adjusted odds ratio for CAS vs. CEA
Death Stroke MI p<.001
Death Stroke p .002
Death p .013
Stroke p .021
MI p .181
Risk-adjusted 30-day outcomes of carotid stenting and endarterectomy: Results from the SVS Vascular Registry , 25 November 2008 
Anton N. Sidawy, Robert M. Zwolak, Rodney A. White, Flora S. Siami, Marc L. Schermerhorn, Gregorio A. Sicard, Outcomes Committee for the Society for Vascular Surgery 
Journal of Vascular Surgery 
January 2009 (Vol. 49, Issue 1, Pages 71-79)

32. Microemboli during CAS: Diffusion weighted MRI
Reduction of postprocedure microemboli following retrospective quality assessment and practice improvement measures for carotid angioplasty and stenting , 12 January 2009 
Maureen M. Tedesco, Ronald L. Dalman, Wei Zhou, Sheila M. Coogan, Barton Lane, Jason T. Lee 
Journal of Vascular Surgery 
March 2009 (Vol. 49, Issue 3, Pages )