1. Πόσο σίγουροι είμαστε για το όφελος της ενδαρτηρεκτομής; Γεώργιος Ντάιος Παθολογική Κλινική & Ομώνυμο Ερευνητικό Εργαστήριο Ιατρική Σχολή Πανεπιστημίου Θεσσαλίας Heart Vessels Stroke Αthens, 27-01-2013

2. Disclosures Support to attend conferences: Bayer; Sanofi-Aventis; Pfizer; Lundbeck; Boehringer-Ingelheim; Bristol Myers Squibb; Galenica. Honoraria: Quintiles; CHUV. Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis. National coordinator (Greece) for the ENOS trial.

4. JAMA 1995; 273:1421-1428

5. ACAS: Asymptomatic Carotid Artery Study JAMA 1995; 273:1421-1428 5.1% 11%

6. Lancet 2004; 363: 1491–502

7. ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

8. ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

9. Stroke 2011; 42(8):e464-540

10. It is reasonable to perform carotid endarterectomy in asymptomatic patients with >70% internal carotid artery stenosis if the risk of perioperative stroke, MI, and death is low. (Level A, Class IIb) Stroke 2011; 42(8):e464-540

11. ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

12. Number-Needed-to-Treat: 40 (to prevent 1 stroke in 5 years)

14. Best (???) medical treatment

16. Lancet 1996; 348: 1329–39

17. CAPRIE: Clopidogrel vs. Aspirin Lancet 1996; 348: 1329–39

18. Lancet 2006; 367: 1665–73

19. ESPRIT: Aggrenox vs. Aspirin Lancet 2006; 367: 1665–73

20. Best (???) medical treatment - Better antiplatelets are available now

21. ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

22. ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

23. Stroke 2008; 39: 3297–3302

25. Best (???) medical treatment - Better antiplatelets are available now - 30% did not receive statin

26. Stroke 2009; 40:e573– e583

28. Excellent safety record  an annual minimum of 12 carotid endarterectomies  mortality/morbidity rate <3% in the last 50 cases.  40% of initial applicants were rejected  2 strokes/deaths  temporarily suspended ACAS: Asymptomatic Carotid Artery Study

29. Subgroup analysis ?

30. ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

31. Stroke 2004; 35:2425-2427

32. Lancet 2005; 365:176-86

36. Subgroup analysis

37. Risk stratification ?

38. Degree of stenosis Stroke 2000; 31:615-621

39. Plaque surface

40. Stroke 2011; 42:972-978 Total plaque area

41. Stroke 2006; 37:818-823

42. Radiology 2009; 252: 502-8

43. Intraplaque hemorrhage Radiology 2009; 252: 502-8

44. Lancet Neurol 2010; 9: 663–71 Microembolic signals

45. Lancet Neurol 2010; 9: 663–71

46. Microembolic signals Lancet Neurol 2010; 9: 663–71

48. Silent strokes J Vasc Surg 2009;49:902-9

49. Silent strokes J Vasc Surg 2009;49:902-9

50. Risk stratification -Degree of stenosis -Plaque surface -Total plaque area -Fibrous cap -Intraplaque hemorrhage -Microemboli -Silent strokes

51. Take home messages