1. What’s new in carotid intervention?
Theodore R. Sullivan, MD, FACS, RVT
Surgical Care Specialists/Vascular

2. History Thomas Willis Sir Astley Cooper Ramsey Hunt Egas Moniz
•  1684
•  1808
•  1913
•  1927
•  1951
•  1953
•  1980
Thomas Willis
“Cerebri Anatome”
Sir Astley Cooper
carotid ligation
Ramsey Hunt
loss of pulsation and “brain softening”
Egas Moniz
cerebral angiogram
C. Miller Fisher
predicted carotid bypass
Michael Debakey
Mullan…first carotid angioplasty
4/5/17 2

3. Carotid pathophysiology
•  Intimal injury
tobacco, lipids, hypertension
•  Shear forces at the bifurcation
•  Immunocellular response to injury
inflammation
•  Plaque build up with potential for
ulceration
•  Embolization
•  Thrombosis

4. NASCET ACAS ACST-I Medical 26% 11% 10% CEA 9% 5.5% 4.1% CEA TRIALS
N Engl J Med 1991; 325: August 15
JAMA May 10;273(18):1421-8
The Lancet, 376, 2010 September:

5. Minimally invasive surgery, Interventional
Radiology and Cardiology

6. Carotid stenting
‘Cheese grater effect’

7. Duplex imaging and CT angiography

8. “High risk”

9. CEA

10. Plaque ulceration
4/5/17 10

11. CEA

12. CEA at 1 week and 6 months

13. Vascular Quality Initiative
a clinician driven database • 
24,201 CEAs reported in 17 regions from 2011 – 2015 • 
24 % symptomatic
45 % Beta blockers, 81 % statins
30 day stroke/death %
2.1 % MI rate
LOS 1.3 days
Reoperation for neck hematoma %
CN injury 4.0%, % permanent

14. • 2502 pts. randomized CEA v CAS with no medical arm
Carotid Revascularization Endarterectomy v Stenting
Trial
•  2502 pts. randomized CEA v CAS with no medical arm
•  Periprocedural risk
CEA
2.3
CAS
4.1
1.1
Stroke MI
•  No difference at 4 and 10 years

15. Cranial nerve injury • ECST 1739 CEAs • 3.7 % at discharge
•  0.5 % at 4 month f/u

16. Carotid Revascularization Endarterectomy Stent
Trial

17. Aortic arch disease

18. Access for carotid stenting

19. Restenosis?

20. Trans-cervical flow reversal

21. Trans-cervical flow reversal

22. Hybrid techniques for carotid intervention

23. Consensus