When is Carotid

Endarterectomy Preferable

to Carotid Stenting?

William Pevec, MD Professor and Chief

Division of Endovascular and Vascular Surgery

UC Davis School of Medicine

• No significant financial relationships exist

between the topics in this presentation and

the speaker

Pathophysiology of Stroke

• Emboli from unstable carotid plaque.

Pathophysiology of Stroke

• Emboli from unstable carotid plaque.

Purpose of arterial stenting

• Increase lumen

– Rarely are strokes due to hemodynamic effect

of carotid stenosis

Purpose of arterial stenting

• Increase lumen

– Rarely are strokes due to hemodynamic effect

of carotid stenosis

• Stenting is not logical in carotid disease

SAPPHIRE (Yadav, NEJM 2004; 351:1493-501)

• Symptomatic stenosis > 50%

• Asymptomatic stenosis > 80%

• “High risk”: – Significant cardiac disease

– Severe pulmonary disease

– Contralateral carotid occlusion

– Recurrent carotid stenosis

– Age > 80 years

– Prior RND or radiation of neck

– Contralateral laryngeal nerve palsy

SAPPHIRE

• 334 patients randomized : – Carotid Endarterectomy

– Carotid Stenting

• 30 day Stroke or Death:

–Stent 4.8%

–Endarterectomy 5.6%

Outcome at 3 years (Gurm, NEJM 2008; 358:1572-9)

Stent CEA p

Death 18.6% 21.0% 0.68

MI 5.4% 8.4% 0.39

Stroke 9.0% 9.0% 0.99

Stroke, MI,

or Death

24.6% 26.9% 0.71

Market Assessment,

circa 2005 • 75% of carotid procedures would be stents

CEA

CAS

SPACE (Lancet Neurology 2008; 7:893-902)

• Symptomatic carotid stenosis > 70%

• Randomized, stent vs. endarterectomy

• 1,214 patients

SPACE

Outcome at 2 years

Stent CEA HR

Any Stroke 10.9% 10.1% 1.10

Any Death 6.3% 5.0% 1.11

EVA-3S (NEJM 2006; 355:1660-71)

• Symptomatic carotid stenosis > 60%

• Randomized, stent vs. endarterectomy

• 520 patients

EVA-3S

Outcome at 30 days

Stent CEA p

Death 0.8% 1.2% 0.68

MI 0.4% 0.8% 0.62

Nonfatal

Stroke

8.8% 2.7% 0.004

Stroke or

Death

9.6% 3.9% 0.01

Ipsilateral stroke Any stroke Any stroke/death

EVA-3S at Four Years

Lancet 2008; 7:885-92

ICSS (Lancet 2010;375:985-997)

• Symptoms within 12 months – 95% had symptoms within 6 months

• > 50% stenosis – 90% had > 70% stenosis

• Eligible for CAS or CEA

• 1713 patients

ICSS (Lancet 2010;375:985-997)

For patients with symptomatic carotid disease,

endarterectomy is safer than stenting

What about

asymptomatic

patients?

CREST (Brott NEJM 2010; 363:11-23)

• NIH sponsored

• “Conventional risk” patients

• Randomized, CEA vs CAS with EPD

– Symptomatic > 50%

– Asymptomatic > 70%

Periprocedure Stroke or Death, or

Late Ipsilateral Stroke

CAS CEA P CAS CEA P

Asymptomatic 2.5% 1.4% 0.15 4.5% 2.7% 0.07

Symptomatic 6.0% 3.2% 0.02 8.0% 6.4% 0.14

30 days 4 years

CEA vs CAS

Asymptomatic Patients J Vasc Surg 2013;57:627-34

• CA hospital discharge data, 2005-09

– CEA 36,524

– CAS 6053

Peri-op Stroke or Death p

CEA 1.8 <0.001

CAS 4.1

Effect of Age

Effect of Age

CREST 30 Day Outcomes, Stenting

Based on Age

> 80 yo (%)

n = 99

< 80 yo (%)

n = 650

P

Death 2.0 0.6 0.14

Stroke 12.1 2.8 <0.0001

Death or Stroke 12.1 3.2 <0.0001

SVS Registry,

J Vasc Surg 2012;55:1313-21

SVS Registry,

J Vasc Surg 2012;55:1313-21

SVS Registry,

J Vasc Surg 2012;55:1313-21

What about the

“Real World”

0%

2%

4%

6%

8%

10%

12%

Stroke/MI/Death Stroke

Asymptomatic (n=3,018) Symptomatic (n=233)

Death MI

ACAS

NASCET

5.4

12.0

1.3

4.8 4.1

8.9

0.8 1.7

CAPTURE 30 day procedural risk

What about those increased

myocardial infarctions?

Kaplan-Meier survival curves after randomized carotid revascularization in the Carotid

Revascularization Endarterectomy Versus Stenting Trial (CREST).

Blackshear J L et al. Circulation 2011;123:2571-2578

Copyright © American Heart Association

CREST

• Mortality at 4 years, any stroke: 20%

– 2x mortality for those without stroke

• Stroke rate was 2x higher with CAS vs CEA

– Negates the advantage of fewer MI

(Oxford neurologist)

When is Carotid Endarterectomy

Preferable to Carotid Stenting?

When is Carotid Endarterectomy

Preferable to Carotid Stenting?

• Symptomatic patients

When is Carotid Endarterectomy

Preferable to Carotid Stenting?

• Symptomatic patients

• Asymptomatic patients

When is Carotid Endarterectomy

Preferable to Carotid Stenting?

• Symptomatic patients

• Asymptomatic patients

• Patients over the age of 65

When is Carotid Stenting Preferable

to Carotid Endarterctomy?

• Anatomic reasons:

–Prior neck radiation

–Prior neck dissection

–Tracheostomy

–Recurrent stenosis

–High bifurcation

• Thank you, Dr. Southard