In patients with carotid artery stenosis what is the best method of approaching carotid repair, surgical or minimally invasive? After research including medical journals such as AHA, ACC guidelines and Cochrane library the answer is inconclusive.

1. CAROTID STENTING VS. ENDARTERECTOMY
BY: KHALED GHANAYIM
DEPARTMENT OF CARDIOLOGY ICU, AFULA HAEMEK

2. INTRO
• Woman 66 y/o
• Hyperlipidemia, hypertension, and smoker.
• Recent MI + PCI to RCA 1 month prior.
• During follow up murmur heard over right carotid.
• Diagnosis of carotid artery stenosis was made.

5. OVERVIEW
• Background
• Comparison
• Study
• Discussion
• Conclusion

6. BACKGROUND
Carotid artery stenosis:
• Narrowing of carotids due to atherosclerosis.
• Prevalence:
- Asymptomatic stenosis: 0.2% in men < 50 years.
- 7.5% in men and 5.0% in women 80 years or older.
• Responsible for 10% - 15% of ischemic strokes.

7. BACKGROUND
• Numerous RCTs showed carotid intervention – Carotid endarterectomy (CEA) - reduced risk of ipsilateral stroke
in patients with severe carotid artery stenosis*.
• This effect was observed significantly in symptomatic patients (stroke <6 months prior).
• Also observed in asymptomatic patients**.
• Carotid artery stenting (CAS) was introduced as a minimally invasive alternative.
* ECST 1998, NASCET 1991
** ACAS 1995

8. CEA vs. CAS
• CEA is a widely known and performed procedure.
• CAS is a newer and minimally invasive alternative.
• Various RCTs were performed to determine which is superior.
CEA CAS
PROS - Well known and researched
- Abundance of data for long term outcomes
available
- Minimally invasive
- Shorter hospital stay
- Suitable for almost all patients
- No visible scars
CONS - Requires anesthesia
- Risk of local nerve/structural damage
- Not suitable for patients with comorbidities
- Surgical scar
- Relatively new
- Lacking data on long term effects

9. COMPARISON
• To determine differences a literature review of various trials and sources was conducted.
• Sources including: American Stroke Association (ASA) – guidelines and meta analysis, American
college of cardiology (ACC) - review, Cochrane library (2018 systematic review).

11. PRISMA diagram of
included RCTs

12. STUDY CHARACTERISTICS
• 5 RCTs total of 4534 patients – 3019 asymptomatic.
• Of 3019 asx 1881 randomized to CAS and 1138 randomized to CEA.
• Every RCT used EPDs – except Brooks et al.
• Median follow-up ranged from 30 days to 10 years.

13. PATIENTS CHARACTERISTICS
• Mean ages: range between 67.8 and 69.3 years
• Proportions of women ranged between 34.4% and 39.9%
• More than 91.8% of patients presented with an ipsilateral stenosis of ≥70% in 4 reporting trials
• Between 88.0% and 90.4% of enrolled patients had hypertension
• Proportion of smokers: 23.2% to 90.6%
• Proportion of diabetes mellitus: 14.1% to 34.8%

14. PERIPROCEDURAL
OUTCOMES

15. LONG-TERM OUTCOMES

20. ACC
GUIDELINES
SUMMARY

21. DISCUSSION
• Clinical equipoise between CAS and CEA with respect to long-term stroke and the
composite outcome of periprocedural stroke, death or MI, or long-term ipsilateral stroke.
• CAS may potentially increase the risk of any periprocedural stroke, periprocedural
nondisabling stroke, and any periprocedural stroke or death.
• CEA holds greater risk for periprocedural MI, cranial nerve palsy, and hematoma.
• Overall CEA showed less adverse outcomes especially in patients over 70 years.

22. CONCLUSION
• Both procedures are similar with regard to long term major outcomes.
• Differences lay in the periprocedural period.
•CAS is a viable alternative in patients with high risk for surgical
intervention or contraindications for CEA.
• CEA seems to be the safer and more efficacious treatment
for asymptomatic carotid artery stenosis.
• Further studies are needed to evaluate CEA vs. CAS in asx patients.

23. WHAT THE FUTURE HOLDS?
• Two trials (SPACE-II and CREST-II) are currently underway.
Comparing efficacy and safety of BMT alone vs. CAS plus BMT or CEA plus BMT
• BMT alone for asx patients?
• CAS as primary recommendation?

24. THANK YOU FOR LISTENING!