Amit Gossain
72 yo male presenting for follow up physical exam <ul><li>PMHx: </li></ul><ul><li>CAD </li></ul><ul><li>HL </li></ul><ul><...
Physical Exam <ul><li>General: NAD </li></ul><ul><li>HEENT: PERRL, NCAT,  </li></ul><ul><li>CV: +S1, +S2 RRR no m/g/r or J...
What’s the next step? <ul><li>Cerebral angiography  </li></ul><ul><li>Carotid duplex ultrasound  </li></ul><ul><li>Magneti...
Clinical Question <ul><li>In what cases is a carotid angioplasty and stent better than carotid endartectomy (CEA) </li></ul>
Indications <ul><li>CEA </li></ul><ul><li>Symptomatic disease </li></ul><ul><ul><li>TIA, Amaurosis fugax </li></ul></ul><u...
Decisions <ul><li>72 yo male with PMHx of HL, HTN, DM. asymptomatic 80% stenosis on ultrasound </li></ul><ul><li>54 yo mal...
EVA-3S <ul><li>Hypothesis: CAS not inferior to CEA for treatment of severe symptomatic carotid stenosis. </li></ul>Exclusi...
 
 
<ul><li>Criticism: </li></ul><ul><li>- lack of experience by the interventionalists </li></ul><ul><li>- prerequisite was t...
SPACE: The Final Frontier <ul><li>Hypothesis: CAS not inferior to CEA for treatment of severe symptomatic carotid stenosis...
 
 
 
<ul><li>Criticism: </li></ul><ul><li>- embolic protection devices with stenting was optional (although no significant diff...
SAPPHIRE trial <ul><li>Hypothesis: CAS is not inferior to CEA in patients with either symptomatic or asymptomatic carotid ...
 
 
 
<ul><li>Criticism: </li></ul><ul><li>- bias towards CAS due to high number of patients with recurrent CAS </li></ul><ul><u...
Cases Revisited <ul><li>72 yo male with PMHx of HL, HTN, DM. asymptomatic 80% stenosis on ultrasound </li></ul><ul><li>54 ...
Conclusions <ul><li>No study has appropriately defined roles of CAS vs CEA </li></ul><ul><li>American Heart Association AN...
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CEA vs. CAS (CQC)

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CEA vs. CAS (CQC)

  1. 1. Amit Gossain
  2. 2. 72 yo male presenting for follow up physical exam <ul><li>PMHx: </li></ul><ul><li>CAD </li></ul><ul><li>HL </li></ul><ul><li>DM </li></ul><ul><li>Medications: </li></ul><ul><li>Vytorin </li></ul><ul><li>HCTZ </li></ul><ul><li>Amlodipine </li></ul><ul><li>Metformin </li></ul>
  3. 3. Physical Exam <ul><li>General: NAD </li></ul><ul><li>HEENT: PERRL, NCAT, </li></ul><ul><li>CV: +S1, +S2 RRR no m/g/r or JVD +carotid bruits </li></ul><ul><li>Lungs: CTA no r/r/w </li></ul><ul><li>Abd: soft, NTND, no organomegaly </li></ul><ul><li>Extremities: no c/c/e </li></ul>
  4. 4. What’s the next step? <ul><li>Cerebral angiography </li></ul><ul><li>Carotid duplex ultrasound </li></ul><ul><li>Magnetic resonance angiography </li></ul><ul><li>Computed tomographic angiography </li></ul>
  5. 5. Clinical Question <ul><li>In what cases is a carotid angioplasty and stent better than carotid endartectomy (CEA) </li></ul>
  6. 6. Indications <ul><li>CEA </li></ul><ul><li>Symptomatic disease </li></ul><ul><ul><li>TIA, Amaurosis fugax </li></ul></ul><ul><li>Asymptomatic disease </li></ul><ul><ul><li>For stenosis of 60-99% </li></ul></ul>
  7. 7. Decisions <ul><li>72 yo male with PMHx of HL, HTN, DM. asymptomatic 80% stenosis on ultrasound </li></ul><ul><li>54 yo male with PMHx of CAD with recent history of TIAs and 60% stenosis on ultrasound </li></ul><ul><li>84 yo male with PMHx of COPD, CAD, DM with bilateral carotid stenosis of 70%. </li></ul>
  8. 8. EVA-3S <ul><li>Hypothesis: CAS not inferior to CEA for treatment of severe symptomatic carotid stenosis. </li></ul>Exclusion Criteria: - high-risk patients with unstable angina, uncontrolled DM, uncontrolled HTN, previous carotid revascularization Mas JL et al, “ Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial” Lancet Neurol. 2008 Oct;7(10):885-92. Epub 2008 Sep 5.
  9. 11. <ul><li>Criticism: </li></ul><ul><li>- lack of experience by the interventionalists </li></ul><ul><li>- prerequisite was two stent procedures with any new device </li></ul><ul><li>- embolic protection for patients was optional early in trial </li></ul><ul><li>- those treated with embolic protection were significantly lower (7.9 vs. 25%!) </li></ul>
  10. 12. SPACE: The Final Frontier <ul><li>Hypothesis: CAS not inferior to CEA for treatment of severe symptomatic carotid stenosis </li></ul>Eckstein HH, et al. “Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial.” Lancet Neurol. 2008 Oct;7(10):893-902. Epub 2008 Sep 5.
  11. 16. <ul><li>Criticism: </li></ul><ul><li>- embolic protection devices with stenting was optional (although no significant difference in primary outcomes) </li></ul>
  12. 17. SAPPHIRE trial <ul><li>Hypothesis: CAS is not inferior to CEA in patients with either symptomatic or asymptomatic carotid stenosis who are considered high risk for surgery </li></ul>Yadav JS, et al. “Protected carotid-artery stenting versus endarterectomy in high-risk patients.” NEJM 2004 Oct 7; 351(15):1493-501
  13. 21. <ul><li>Criticism: </li></ul><ul><li>- bias towards CAS due to high number of patients with recurrent CAS </li></ul><ul><ul><li>- complication rates higher with repeat/redo CEA due to higher rates of embolization </li></ul></ul><ul><li>- high incidence of MI in perioperative period in CEA </li></ul>
  14. 22. Cases Revisited <ul><li>72 yo male with PMHx of HL, HTN, DM. asymptomatic 80% stenosis on ultrasound </li></ul><ul><li>54 yo male with PMHx of CAD with recent history of TIAs and 60% stenosis on ultrasound </li></ul><ul><li>84 yo male with PMHx of COPD, CAD, DM with bilateral carotid stenosis of 70%. </li></ul>
  15. 23. Conclusions <ul><li>No study has appropriately defined roles of CAS vs CEA </li></ul><ul><li>American Heart Association AND American Stroke Association made statements saying more definitive evidence needed for CAS. </li></ul><ul><li>Gold Standard still CEA , BUT CAS has a role </li></ul><ul><ul><li>CAS not inferior in patients that are “high risk” (SAPPHIRE trial) </li></ul></ul><ul><ul><li>CAS appears to be beneficial in younger populations (68yrs and younger) </li></ul></ul>
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