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
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