Management of cervical carotid disease. What CREST has taught us? Francesco Serino MD, Vascular Surgeon

Heart and Vascular Institute, Cleveland Clinic Abu Dhabi

Carotid endarterectomy (CEA)

has been shown to decrease the

long-term risk of stroke

compared with medical therapy.

Percutaneous techniques such as

carotid artery angioplasty

with stenting (CAS) are less

invasive and a viable option for

the treatment of carotid artery

disease.

Treatment of Significant Carotid Disease

To stent or not to stent ?

Current Guidelines Summary

Male %stenosis method Age/life therapy note

70-99% nascet ≥ 5 yrs CEA H.R. CAS

50-69% nascet medical

Female

70-99% nascet medical

50-69% nascet medical

Male %stenosis method Age/Life therapy note

70-99% nascet CEA U.A. CAS

50-69% nascet CEA

Female

70-99% nascet CEA

50-69% nascet Medical

Asymptomatic

Symptomatic

the female factor Vrujenhek JEP, Stroke 2013 44:3318-23

1422 plaques analyzed

Search for intra plaque hemorrhage by histology

Men had higher prevalence of PH

PH is related to secondary CVD symptoms in man and not in

women

Long term mortality in men after CEA

the “Doppler” factor Vrijenhoke JEP, Atherosclerosis, 2014

Large lipid core have lower PSV

Female sex associated with higher PSV

Male/Female

The “high risk” patient

Risk outcome CEA/CAS surce

Radiation Cardiovascular events

Cerebrovascular events

Temp. cranial nerve inj

restenosis

=

=

˃

˂

Fokkema TM, Stroke

2012;43:793-801

Previous CEA CVE

Restenosis

Cardio Vascular Events

=

=

= (˃ vs primary int)

VSG New England

JVS 2013

And meta-analysis

Controlateral

stenosis/occlusion

Stroke/death asymptomatic

Stroke/death symptomatic

= (increased vs non CLD if

≥ 80%)

= (increase vs non CLD if ≥

50%)

G.J.De Borst.

Un Uthrect (p.c.)

Urgent procedures

Re exploration

Transient Cranial Nerve

injury

Persistent CNI

4.9%

0.7%

* No redo

Fokkema.M EJVES 2013

Mixed : medical and

anatomical criteria by

Center Medical Services

criteria (ASA)

Peri op stroke

TIA

MACE

death

˂

˂

˂

˂

Schermerhorn ML JVS

2013;57:1318-24

randomized trial designed to compare the efficacy of stenting in patients with

average surgical risk.

• It included 2502 patients, 53% of whom were symptomatic.

• The trial’s primary endpoint was the combined incidence of stroke, myocardial

infarction (MI), and death from any cause. Secondary endpoints included

incidence of restenosis, post-procedure morbidity, quality of life, cost

effectiveness, and outcomes among different subgroups considered at high risk.

• At a median of 2.5 years of follow-up, the incidence of the composite endpoint

of death, MI, and stroke was not different between CAS and CEA (7.2% vs.

6.8%; hazard ratio [HR], 1.11; p = .51), with no difference in the treatment effect

based on symptomatic status or gender.

• The incidence of MI was higher in the endarterectomy group (1.1% vs. 2.3%; p

= .03).

• The incidence of any stroke within 30 days after the procedure was significantly

higher in the CAS group (4.1% vs. 2.3%; p = .01).

there was no difference in the incidence of major stroke between the groups

(0.9% for CAS vs. 0.7% for CEA).

The CREST study

An important finding of the CREST trial was that the

impact on quality of life at 1 year of intervention was

greatly reduced in patients with major or minor stroke but

not in those with MI. This was caused by the use of

biomarkers in the diagnosis of myocardial ischemia that

included many myocardial events of questionable clinical

significance, inflating the incidence of MI.

In CREST, there was a slight difference in outcomes at 4

years of follow-up, with patients older than 70 years faring

better with CEA, and patients younger than 70 years

faring better with CAS.

The CREST study, comments

In the EVA-3S trial, at 4 years of follow-up, the cumulative probability of

procedural stroke or death and nonprocedural stroke was higher in the CAS

group (11.1 vs. 6.2; p = .03). However, this difference was derived mainly from

the 30-day peri procedural complication rates, and after that period the risk of

ipsilateral stroke was equivalently low for both procedures.

The SPACE trial, at 2 years of follow-up, found no significant difference in the

incidence of the composite endpoint of ipsilateral stroke and periprocedural

stroke or death between CAS and CEA (9.5% vs. 8.8%; p = .31).

the ICSS trial early results published in 2011 revealed a higher incidence of the

combined endpoint of stroke, death, and MI at 4 months from randomization in

the CAS group compared with CEA (8.5% vs. 5.2; p = .006). Interestingly, and in

contradiction to the CREST trial, the ICSS trial found no difference in the

incidence of MI between the two treatment groups, but there were three deaths

from MI in the CAS group, whereas no cardiac-related deaths occurred in

patients treated with CEA

Other comparative studies

meta-analysis of the early results (120 days from inclusion in the

trial) of these three trials including a total of 3433 patients

• the incidence of any stroke or death in patients undergoing CAS

was significantly higher than that for CEA (8.9% vs. 5.8%; p =

.0006).

• This meta-analysis suggested that the difference in early

outcomes is derived from the twofold higher rate of

complications for CAS that occurred in patients 70 years of age

or older, compared with those undergoing CEA in the same age

group (12% vs. 5.9%; p = .0053).

• The meta-analysis found no difference in the risk of stroke or

death between CAS and CEA in patients younger than 70 years

Meta-analysis

Currently, there is no question that CEA, in

the appropriate hands, remains the best

option for treating carotid artery disease

under most circumstances. However, there

is no doubt that the safety and efficacy of

CAS, in its current form, is acceptable in

some clinical situations and that many

patients have and will benefit from it

Evidence

Point of views

13

CEA vs Stent

14

CEA vs Stent

Thank you