1. J M CARDON PRIVATE HOSPITAL FRANCISCAINES NIMES FRANCE

2.  First cause of mortality cardiac events: 683 170  Second stroke : 372 534  Third cancer: 293 602 Infografika 2012

3. TCMM 1977 Easton JD 21,1%

4. TCMM Série Historique 1977 Easton 6,5 % 2,8 % 2,8% 2006 EVA 3S 3,9 % 15000 cases in France NASCET 1991 ACAS 1995 EVA 3 S 2006

5.  Symptomatic stenoses NASCET2885 patients1987-1996 ECST3024 patients1981-1994  Asymptomatic stenoses ACAS1659 patients1987-1993 ACST3125 patients1995-2003

7. Sténoses > 70 % NASCET2885 patientsNEJM 1991 ECST3024 patients Lancet 1991 ↓ R. Abs ↓ R. Relat NST / 1 stroke stroke Avoided for 1000 CEA NASCET 17 %65 % 6 170 ECST8,5 %*45 %1283

8. Sténoses 50-69 % NASCET858 patientsNEJM 1998 ECST646 patients Stroke 2003 ↓ R. Abs ↓ R. Relat NST / 1 sroke sroke Prevented by 1000 CEA NASCET 8,4%26% 12 83 ECST 5,7% - - -

9. Age > 75 (Nascet NST 3 vs 6) stroke vs TIA men vs women central vs retineal

10. <2 sem2-4 sem4-12 sem>12 semp ECST6,5%6,4%7,4%8%0,86 NASCET7,1%5,0%6,5%7,4%0,64 Total6,9%5,7%7,0%7,8%0,48

11. Reduction of absolute risk of stroke and mortality at 5 years according to the delay of surgery Rothwell : stroke 2004

12. Stroke risk 7 days10 % 30 days15 %

13.  Angio MRI or scan in less than 24 h  Duplex doppler  Cardiac screening  Hospitalisation if ABCD2 ≥ 3

15.  ACAS1995Jama  ACST-12004Lancet 2010  Level 1 grade A evidence supporting CEA  In highly selective asymptomatic patents with a stenosis > 60 % CEA conferred a 50 % relative risk reduction of stroke at 5 years

16. Sténoses > 60 % ACAS1662 patientsJAMA 1995 ACST3120 patients Lancet 2004 ↓ R. Abs ↓ R. Relat NST / 1 AVC stroke Avoided for 1000 CEA ACAS 5,9 %53 %1953 ACST5,4 %45 %1854

20. Subgroup analysis  Degre of stenosis does not influence the results  better for men vs women (↓ r.a 8 / 1,4 %)  benefit arrive after 1 years  younger <75 years have more benefit than older

22. USA 2005 Endartériectomie 135 701 92 % asymptomatique

24.  With the use of statins in ACTS-1  The evidence of stroke fell strongly in the medical arm  But it fall strongly as well is the CEA arm.  So the difference is still highly significant

27. NO BENEFIT FROM CEA Symptomatic Asymptomatique < 50% NASCET < 60% NASCET

28. R. AbsR. RelatNST / 1 stroke stroke Avoided by 1000 CEA NASCET 17 %65 % 6 170 ECST8,5%45%1283

29. R. AbsR. RelatNST / 1 stroke Stroke avoided by 1000 CEA Sténoses Symptomatic 50-69 % NASCET 6,5%29% 15 67 Sténoses Asymptomatic > 60 % NASCET 5,9%53%17 59

30.  TIA are emergencies  Symptomatic patient have to be treated within 15 days  The degree of stenosis does not influence the stroke risk in asymptomatic patient with stenosis >60%  TCMM must be < 3% to operate asymptomatic patient

32. N TCMMResténose ou occlusion Ballotta 1999 Eversion 16900 Patch 1672,3%4,9% Green 2000 Eversion 1070,9%4,6% Patch 1673%4,7% Everest Trial 2000 Eversion 6782,2%3,6% EC 6751,6%9,2% Cochrane DB 2003 Eversion 11901,7%2,5% EC ± patch 11732,6%5,2% Cochrane 2003

33. Pour LESS RESTENOSIS NO CLINICAL BENEFIT SURGEON CHOICE Notre opinion TECHNIC Eversion

34. G

35. N TCMM periop TCMM Fw-up Resténose occlusion Patch 9362,3 %13 %4,3 % Suture directe8333,7 %20 %13,7 % NSSS 2009

36. MAY REDUCE RESTENOSIS AND OCCLUSION RATE REDUCE IPSILATERAL POST OP STROKE RATE REDUCTION IN POST OP TCMM RATE

37. Dacron Collagène vs PTFE 2004

38. 2009

39. Avantage : hémodynamic and morphologic data N AbnormalitiesFU (mois) RESTENOSE Normal vs minor abnormal Baker 1994 31619,6%21,64,3% vs 17% Ascher 2004 6502,3%--

40. comparative study angioNo angio NTCMM %N Roon 1992 5351,3%1574,5% Ricco 1996 1120,9%1143,5%

42. STROKE + DEATH +MI 30ème jour GA 4,8 % LA 4.5 % Quality of life (1 month) intervention time ICU stay hospital stay 3526 patients NO différence

44.  no major differrence between tecnics but eversion or systematic patch better than direct suture  No proof for shunting :never,sometimes or always  Local or geneneral anesthesia are equivalent  Heparine reversal have no impact on stroke or MI risk

45.  NEVER FOR SYMPTOMATIC PATIENT: Eva 3s, space, icss, crest: Risk x 3 comparing with CEA  Not for old > 80 years  Anatomy suitable for CAS

47. Registres prospectifs NTCMM Hobson (Crest) 99 12% 2004 Stanziali (Pittsburgh) 87 9,2% 2005 Gray (Capture) 594 7,9% 2006

48.  Equivallence with CEA in crest  More than 100 CAS experience to get skills  Answer with ACST 2 study: work in progres

49. Progres in CAS  8F Transcervical Arterial Sheath  8F Venous Return Sheath  Large bore flow reversal circuit  Flow controller with stop, HI and LO flow

50. CEA CAS  2010 88 20  2011 102 26  2012 86 43