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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
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