1. Carotid Stenosis: Asymptomatic Patients are not all Created Equal: Indications for Intervention
Rabih A. Chaer MD
Assistant Professor of Surgery
Division of Vascular Surgery
University of Pittsburgh Medical Center

2. Rabih A. Chaer, MD DISCLOSURES
I have no real or apparent conflicts of interest to report.

3. ACAS CEA Reduces Stroke Risk
Asymptomatic Carotid Stenosis Risk Reduction at 5 Years
>60%stenosis from 11% to 5%
(< 3 % without angiography)
Men benefit significantly more than women
CEA appropriate if Death/Stroke Risk < 3%
and
Patient has a reasonable life expectancy

4. USA CEA VOLUME (NCHS) YEARS ACAS NASCET ASYMPTOMATIC UK: 16% USA: 80%D
ACAS
NASCET
ASYMPTOMATIC
UK: 16%
USA: 80%
YEARS

5. Choices….Choices

6. CURRENT EVIDENCE VA study: men>50% stenosis, ASA vs. ASA+CEA
ACAS: BMT ± CEA
ACST: immediate vs. deferred CEA
Hobson et al. NEJM 1993; 328:221-7.
ACAS. JAMA 1995;273:
Halliday A et al. Lancet 2004; 363:

7. Risk of Stroke
2% per year in asymptomatic patients with >60% stenosis (ACAS/ACST)
May be higher?
REACH registry: TIA 3.5 vs. 1.6% (p<.0001)
Non fatal stroke 2.65 vs. 1.75% (p<.0009)
Aichner FT et al. European Jl of Neurology. 2009; 16:902-8

8. Level I Pooled data from ACAS and ACST: 4,779 patients:
Net procedural hazard (stroke and death): 2.9%
RR reduction 31% (p=0.001)
Absolute risk reduction 3% over 2-3 years
Number needed to treat: 33 to prevent 1 stroke. Benefit at about 3 yrs post intervention.

9. Patient Selection Modifiers:
Age, gender, previous stroke, silent infarcts
ACAS RRR 50% vs. 9% for age<68 vs. >68
ACST ARR 7.8% vs. 3.3% for age <75 vs. >75
Contralateral symptoms
ACST: higher 5yr gain
Severity of stenosis
Medical therapy
Plaque characteristics

10. High Risk for CAS Anatomic Physiologic Hostile Arch
Severe Tortuosity
Lesion Anatomy
Tandem Lesions
Calcified Lesions
Plaque Characteristics
Physiologic
Symptomatic Patients
Octogenarians
Renal Failure Patients

11. High Risk for CAS: Arch Characteristics
Type III arch
Excessive Tortuosity

12. High Risk for CAS: Lesion Characteristics
Globular Lesions Severe Tortuosity Free Floating Thrombus

13. More Lesion Characteristics
J Vasc Surg 2008; 47:81-87

14. Lesion Location 7.1 7.8 9.1 1.8 2.5 2.9 Location (n) Proc. CVA (%)
30 day CVA (%)
30 day AE (%)
Non Ostial (275)
1.8
2.5
2.9
Ostial (154)
7.1
7.8
9.1 P

15. Lesion Length
Lesion Length in mm (n)
Proc. CVA (%)
30 day CVA (%)
30 day AE (%)
(182)
2.2
2.7
3.3
(105)
1.9
2.9
3.8
> (47)
17.0
19.1
P <

16. Echolucent Lesions N Neuro Complications GSM < 25 155 7.1%
Biasi GM et al: The Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) Study. Circulation 2004;110:

17. The Vulnerable Plaque Well established in the coronary literature
Plaques are not identical and have various biologic behavior in propensity for symptoms or in response to therapy
Most patients receive more than one device (1.5/patient). Long tapering anatomy
Define high-risk = non-surgical (TAA, Dissection, & Trauma)

18. The Vulnerable Plaque
The vulnerable plaque is not only characterized by
Anatomic characteristics such as large lipid core, Intraplaque hemorrhage, or a thin fibrous cap
but also
Pathophysiologic active markers of inflammation
Most patients receive more than one device (1.5/patient). Long tapering anatomy
Define high-risk = non-surgical (TAA, Dissection, & Trauma)

19. The Vulnerable Plaque
A multimodal approach to studying the carotid plaque appears to be a promising tool in identifying vulnerable carotid plaques The current literature suggests that in addition to the degree of stenosis other imaging and biochemical findings have important clinical significance.
Most patients receive more than one device (1.5/patient). Long tapering anatomy
Define high-risk = non-surgical (TAA, Dissection, & Trauma)
Cerebrovasc Dis 2009;27:19–24

20. The Vulnerable Plaque: IVUS VH
Most patients receive more than one device (1.5/patient). Long tapering anatomy
Define high-risk = non-surgical (TAA, Dissection, & Trauma)

21. Vulnerable Plaque: Duplex + Microbubbles
Most patients receive more than one device (1.5/patient). Long tapering anatomy
Define high-risk = non-surgical (TAA, Dissection, & Trauma)
Symptomatic Patient
Before Microbubbles After Microbubbles
Vascularized Plaque
with channel through plaque

22. Vulnerable Plaque: Duplex + Microbubbles
Most patients receive more than one device (1.5/patient). Long tapering anatomy
Define high-risk = non-surgical (TAA, Dissection, & Trauma)
Asymptomatic Patient
Before Microbubbles After Microbubbles
No change in the plaque

23. The Vulnerable Plaque
a self-expanding stent tailored to shield vulnerable plaques (vProtect® Luminal shield)
Most patients receive more than one device (1.5/patient). Long tapering anatomy
Define high-risk = non-surgical (TAA, Dissection, & Trauma)
Nat. Rev. Cardiol. 2009;6:374–378

24. CEA vs CAS
Gray
CAS Always
Neville
Only CEA

25. Asymptomatic CEA vs. CAS RCT
Asymptomatic Cohort in SAPPHIRE
STENT (117) CEA (120)
DEATH % %
CVA % %
DEATH / CVA % %
M.I % %
DEATH / CVA / M.I % %
ACAS (CVA) %
AHA Guidelines (CVA/Death) < 3.0%

26. 30 day AE CAPTURE Study CVA 11.1% 16.7% MI 2.8 All Death 1.9 10.4 2.4%
Non-Octogenarians
Octogenarians
(n = 108)
(n = 48)
Symptomatic Patients
CVA
11.1%
16.7% MI
2.8
All Death
1.9
10.4
2.4%
5.5%
0.8
0.6
1.0
2.1
(n = 1116)
(n = 330)
Asymptomatic Patients

27. REGISTRY CAS DATA
EX and C2 data: 2145 Emboshield/Xact, 4175 Acculink/Accunet
30 day stroke and death rate:
<80yo: 5.3% for symptomatic patients, 2.9% in asymptomatic
>80yo: 10.5% for symptomatic patients, 4.4% in asymptomatic
Gray et al. CCI 2009; 2:

28. Carotid Revascularization: Asymptomatic
No Clear data to answer
Both CEA and CAS may be used effectively
Plaque characteristics matter
We should start clinical evaluation of plaque composition that make them more or less suitable for a particular treatment
Most patients receive more than one device (1.5/patient). Long tapering anatomy
Define high-risk = non-surgical (TAA, Dissection, & Trauma)

29. Asymptomatic Carotid: NOT all the same
Procedural hazards
Life expectancy
Age
Plaque and lesion characteristics
Intracranial circulation: ACA
Medical therapy

30. Insufficient Contemporary level I CAS data
CREST
ACT1
SPACE2
TACIT
ACST-2