2. Epidemiology in HK  Stroke is major cause of morbidity and mortality around the world  4th cause of mortality in HK resulting in >3000 deaths every year Department of Health 2011

3. Stroke  80 % of strokes : ischaemic in orgin  20 – 25 % of ischaemic stroke : carotid stenosis  Risk of stroke correlates with severity of carotid stenosis

4. Treatment options Medical therapy Carotid endarterectomy Carotid artery stenting

5. Carotid Endarterectomy (CEA)  First described in 1953  Widely used invasive treatment for significant carotid stenosis  Efficacy was established by 4 RCTs in late 1980s and early 1990s

6. CEA superior to medical therapy Symptomatic carotid stenosis  North American Symptomatic Carotid Endarterectomy Trial (NASCET)  Carotid stenosis 70 – 99% : 2 yrs stroke reduced from 26% to 9% (p<0.001)  Carotid stenosis 50 – 69% : 2 yrs stroke reduced from 22.2% to 15.7% (p<0.045)  Carotid stenosis <50% : no benefit  European Carotid Surgery Trial (ECST) JM Henry N Eng Jounral of Medicine 1998 PM Rothwell Lancet 1998

7. CEA superior to medical therapy Asymptomatic carotid stenosis  Asymptomatic Carotid Surgery Trial (ACST)  Carotid stenosis >60% : 5 yrs stroke rate reduced from 11.8% to 6.4%  10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1)  10 yrs stroke rate reduced from 17.9% to 13.4%  Asmptomatic Carotid Atherosclerosis Study (ACAS) A. Halliday Lancet 2004 JAMA 1995 A. Halliday Lancet 2010

8. Carotid Endarterectomy (CEA)

9. Emerge of Carotid artery stenting (CAS) 1. Excluded elderly patients (>80 yrs) with significant comorbidites 2. Excluded high risk lesions such as restenosis after prior CEA, radiation induced stenosis... 3. CEA associated complications such as cardiovascular events, wound complications, cranial nerve injury, carotid artery dissection...

10. Carotid artery stenting (CAS)  First case report of carotid angioplasty appeared in early 1980 Embolic- protection device in distal artery Balloon angioplasty across stenotic area Deployment of stent Withdrawl of embolic – protection device

12. 1st RCT (CEA Vs CAS)  Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS)  Performed only angioplasty without EPD  NO significant difference in 30-day incidence of death or disabling stroke (6.4% in CAS vs 5.9% in CEA)  8 yrs follow up : Higher restenosis and stroke rate (21.1% in CAS vs 15.4% in CEA) CAVATAS Investigators Lancet 2001 CAVATAS Investigators Lancet 2009

13. RCTssssssss (CEA Vs CAS) Trial No of patients FindingConclusion SPACE1200 30 days stroke and death rate CAS : 6.84% CEA : 6.34% (p = 0.09) Failed to prove non- inferiorty of CAS EVA – 3S527 30 days stroke and death rate CAS : 9.6% CEA : 3.9% (p = 0.01) Terminated early due to high stroke rate in CAS group ICSS1700 120 days stroke, MI and death rate CAS : 8.5% CEA : 5.2% (p = 0.006) CEA should remain the treatment of choice

14. RCTssssssss (CEA Vs CAS) widely criticized  SPACE, EVA-3S and ICSS were widely criticized  NO roll in phase e.g. SPACE trial : eligible operators for CAS arm do not need prior carotid stenting experience  Use of EPD was not mandatory e.g. SPACE trial : used in 27% of patients

15. CREST Trial  Stenting versus Endartrectomy for Treatment of Carotid – Artery Stenosis (CREST)  National Institutes of Health-sponsored study based in United States from 2000 to 2008  2522 patients including both symptomatic and asymptomatic carotid stenosis  Lead in phase   Single carotid stent with EPD systems Thomas G. Brott N Eng Journal of Med 2010

16. CREST – Periprocedural findingOutcome CEA % CAS % p value Periprocedural stroke+MI+death4.55.20.38 Periprocedural stroke - Major ipslateral stroke - Minor ipsilateral stroke 2.3 0.3 1.4 4.1 0.9 2.9 0.01 0.09 0.009 Periprocedural MI2.31.10.03 Periprocedural death0.30.70.18 Periprocedural cranial nerve injury4.80.30.0001 Thomas G. Brott N Eng Journal of Med 2010

17. CREST – 4 years finding Outcome CEA % CAS % p value 4 years stroke+MI+death6.87.20.51 4 years stroke2.320.085 Thomas G. Brott N Eng Journal of Med 2010

18. CREST Finding – Age Thomas G. Brott N Eng Journal of Med 2010  Younger patients have better outcome with CAS while older patients have better outcome with CEA  120 days stroke and death risk  Age <70 yrs : CAS – 5.8% CEA – 5.7%  Age >70 yrs : CAS – 12% CEA – 5.9%  Arterial tortuosity and calcification in elderly prones to catheter provoked cerebral emboli

19. CEA = CAS ??

20. Are these conclusion justified? 1. Primary purpose of CEA and CAS is to prevent death and stroke Outcome CEA % CAS % p value Perioperative stroke+MI+death4.55.20.38 Perioperative stroke - Major ipslateral stroke - Minor ipsilateral stroke 2.3 0.3 1.4 4.1 0.9 2.9 0.01 0.09 0.009 Perioperative MI2.31.10.03 Perioperative death0.30.70.18 Perioperative cranial nerve injury4.80.30.0001

21. Are these conclusion justified? 2. Stroke ≠ Myocardial Infarction  Quality-of-life analyses indicates that stroke had a greater adverse effect on heath-status than MI  Even minor stroke had full motor and sensory recovery, patient often have other brain damage

22. Are these conclusion justified? 3. CAS operators in CREST have a high level of experience and skill, CREST results may not be representative in real world

23. Carotid Endarterectomy (CEA) Carotid Artery Stenting (CAS) ProsCons ProsCons  Periprocedural stroke  MI  Periprocedural MI  Periprocedural stroke  Cranial nerve injury No cranial nerve injury  Wound infection  Wound infection Required GANo GA required Longer recoveryMinimally invasive

25. Matching patient to intervention  Treatment decisions depends on patient- specific factors 1. Risk factors for CEA 2. Risk factors for CAS Medical Surgical / Anatomical

26. Risk factors for CEA Medical risk factors  CHF and left ventricular dysfunction  Unstable angina or recent MI (<30 days)  Coronary artery disease (CAD)  Open heart surgery needed within 6 weeks  Severe pulmonary dysfunction Mozes J Vasc Surg 2004   risk of worse outcome remains controversial  Similar stroke and death rate between low and high risk patient  Too high risk  Medical treatment

27. Risk factors for CEA Surgical / Anatomical risk factors Surgical Factors  Restenosis after prior CEA  Previous ablative neck surgery (e.g. radical neck dissection, laryngectomy)  Previous neck irradiation  Contralateral vocal cord paralysis  Tracheostomy

28. Risk factors for CEA S urgical / Anatomical risk factors Anatomical Factors  High carotid bifurcation (above C2)  Extension of athersclerotic lesion into intracranial ICA or proximal CCA below clavicle

29. Risk factors for CAS

30. Individualized management  Optimal treatment selection specific for each patient Lowest morbidty rate  Lowest morbidty rate  Most favorable outcomes

31. Management Algorithm HIGH risk for surgery Favourable anatomy for CAS CASCAS Unfavourable anatomy for CAS CEACEA Symptomatic >= 50% CS LOW risk for surgery Asymptomatic >= 70% CS BMTBMT

32. Conclusion  CEA continues to be the gold standard for treatment for carotid stenosis  CAS will evolve as a safe and efficacious therapy for carotid stenosis  Individualized treatment plan