Carotid Artery Stending: A detailed approach
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Transcript of Carotid Artery Stending: A detailed approach
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George Trellopoulos MDPapanikolaou Hospital
Thessaloniki
Course: Carotid Artery Stenting. A detailed approach
CAS or CEA? What is the evidence from the clinical trials?
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Registries & Clinical Trials
• CAVATAS • SAPHIRE• WALLSTENT• SPACE• EVA- 3S• CREST• ACST II, ACST I• ICSS• TACIT
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CAVATASLong-term outcome after angioplasty and stenting for symptomatic vertebral artery stenosis
compared with medical treatment in the Carotid And Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomized trial
Stroke. 2007 May;38(5):1526-30.
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CAVATASLong-term outcome after angioplasty and stenting for symptomatic vertebral artery stenosis compared
with medical treatment in the Carotid And Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomized trial
Stroke. 2007 May;38(5):1526-30.
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SAPPHIREProtected carotid-artery stenting versus endarterectomy in high-risk patients.
N Engl J Med. 2004 Oct 7;351(15):1493-501.
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SAPPHIREProtected carotid-artery stenting versus endarterectomy in high-risk patients.
N Engl J Med. 2004 Oct 7;351(15):1493-501.
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SAPPHIREProtected carotid-artery stenting versus endarterectomy in high-risk patients.
N Engl J Med. 2004 Oct 7;351(15):1493-501.
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SAPPHIREProtected carotid-artery stenting versus endarterectomy in high-risk patients.
N Engl J Med. 2004 Oct 7;351(15):1493-501. •CAS not inferior to CEA in high surgical risk
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SPACE 30 day results from the SPACE trial of stent-protected
angioplasty versus carotid endarterectomy in symptomaticpatients: a randomised non-inferiority trial,
Lancet 2006; 368: 1239–47
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SPACE 30 day results from the SPACE trial of stent-protected
angioplasty versus carotid endarterectomy in symptomaticpatients: a randomised non-inferiority trial,
Lancet 2006; 368: 1239–47
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SPACE 30 day results from the SPACE trial of stent-protected
angioplasty versus carotid endarterectomy in symptomaticpatients: a randomised non-inferiority trial,
Lancet 2006; 368: 1239–47
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SPACE 30 day results from the SPACE trial of stent-protected
angioplasty versus carotid endarterectomy in symptomaticpatients: a randomised non-inferiority trial,
Lancet 2006; 368: 1239–47
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SPACE 30 day results from the SPACE trial of stent-protected
angioplasty versus carotid endarterectomy in symptomaticpatients: a randomised non-inferiority trial,
Lancet 2006; 368: 1239–47
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SPACE 30 day results from the SPACE trial of stent-protected
angioplasty versus carotid endarterectomy in symptomaticpatients: a randomised non-inferiority trial,
Lancet 2006; 368: 1239–47
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SPACE 30 day results from the SPACE trial of stent-protected
angioplasty versus carotid endarterectomy in symptomaticpatients: a randomised non-inferiority trial,
Lancet 2006; 368: 1239–47
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EVA -3SEndarterectomy versus Stenting in Patients with
Symptomatic Severe Carotid Stenosis N. Engl. J. Med 355:16
• multicenter• non-inferiority randomized trial • national research organisation funding
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EVA - 3SEndarterectomy versus Stenting in Patients with Symptomatic Severe
Carotid StenosisN. Engl. J. Med 355:16
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EVA - 3SEndarterectomy versus Stenting in Patients with
Symptomatic Severe Carotid StenosisN. Engl. J. Med 355:16
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EVA - 3SEndarterectomy versus Stenting in Patients with
Symptomatic Severe Carotid StenosisN. Engl. J. Med 355:16
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EVA - 3SEndarterectomy versus Stenting in Patients with Symptomatic Severe
Carotid StenosisN. Engl. J. Med 355:16
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EVA -3S Support 1
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EVA -3S Support 2
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Eva 3S - Support 3
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Meta-analysis of Randomised Trials Comparing Carotid Endarterectomy and Endovascular Treatment
Eur. J. Vasc. Endovasc. Surg, 34 470 -479(2007) CEA vs. CAS
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CREST Carotid Revascularization Endarterectomy versus Stenting Trial:
Curr Control Trials Cardiovascular Med. 2001; 2(4): 160–164.
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CREST Carotid Revascularization Endarterectomy versus Stenting Trial:
Curr Control Trials Cardiovascular Med. 2001; 2(4): 160–164.
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CREST Carotid Revascularization Endarterectomy versus Stenting Trial
LEAD IN PHASE
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CREST
• Summary
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ACST-2Asymptomatic Carotid Surgery Trial
A large, simple randomized trial to comparecarotid endarterectomy versus carotid artery stenting to prevent stroke
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ACST-2Asymptomatic Carotid
Surgery Trial A large, simple randomised trial to comparecarotid endarterectomy versus carotid artery stenting to prevent stroke
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TACIT Transatlantic Asymptomatic Carotid Intervention Trial
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TACIT Transatlantic Asymptomatic Carotid Intervention Trial
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TACIT Transatlantic Asymptomatic Carotid Intervention Trial
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TACIT Transatlantic Asymptomatic Carotid Intervention Trial
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Critical Issue 1Operator’s Experience
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Critical Issue 1Operator’s Experience
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Critical Issue 2:Octogenarians
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Critical Issue 3:Cognitive Changes
Cognitive Changes after Carotid Stenting
Cognitive Changes should be included as End Points in all Clinical Trials
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Critical Issue 4:Protected VS. Unprotected CAS
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Critical Issue 4:Protected VS. Unprotected CAS
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Critical Issue 5:Heterogeneity of Clinical Trials
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Critical Issue 6: High Risk Patients
30-Day MAE Results: CAS High Risk Registries
3.9%4.8%
5.4% 5.4% 5.6% 5.9% 6.2%7.2%
8.3% 8.6%
0%1%2%3%4%5%6%7%8%9%
10%
CABERNET (BSX)
SAPPHIRE (C
ordis
)
MAVErIC I&
II (MDT)
BEACH (BSX)
CREATE Arm
2 (e
v3/G
DT)
MAVErIC In
t'l (M
DT)
CREATE Arm
1 (ev
3)
SECuRITY
(ABT)
ARCHeR III
(GDT)
ARCHeR II
(GDT)
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Critical issue 6: Impacts after Space & Eva 3S
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Critical issue 6: Impacts after Space & Eva 3S
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Critical issue 7: Medical Therapy
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CAS or CEA ?
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Conclusion
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Conclusions