1. CQC
Amit Gossain

2. 72 yo male presenting for follow up physical exam
PMHx:
CAD HL DM
Medications:
Vytorin
HCTZ
Amlodipine
Metformin

3. 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

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

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

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

7. 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%.

8. 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 Oct;7(10): Epub 2008 Sep 5.

11. 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%!)

12. 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 Oct;7(10): Epub 2008 Sep 5.

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

17. 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):

21. - 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

22. 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%.

23. 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)