Carotid Artery Stending: A detailed approach

1. George Trellopoulos MD
Papanikolaou Hospital
Thessaloniki
Course: Carotid Artery Stenting. A detailed approach
CAS or CEA?
What is the evidence from the clinical trials?

2. Registries & Clinical Trials
• CAVATAS
• SAPHIRE
• WALLSTENT
• SPACE
• EVA- 3S
• CREST
• ACST II, ACST I
• ICSS
• TACIT

3. CAVATAS
Long-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.

4. CAVATAS
Long-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.

5. SAPPHIRE
Protected carotid-artery stenting versus endarterectomy in high-risk patients.
N Engl J Med. 2004 Oct 7;351(15):1493-501.

6. SAPPHIRE
Protected carotid-artery stenting versus endarterectomy in high-risk patients.
N Engl J Med. 2004 Oct 7;351(15):1493-501.

7. SAPPHIRE
Protected carotid-artery stenting versus endarterectomy in high-risk patients.
N Engl J Med. 2004 Oct 7;351(15):1493-501.

8. SAPPHIRE
Protected 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

9. SPACE
30 day results from the SPACE trial of stent-protected
angioplasty versus carotid endarterectomy in symptomatic
patients: a randomised non-inferiority trial,
Lancet 2006; 368: 1239–47

10. SPACE
30 day results from the SPACE trial of stent-protected
angioplasty versus carotid endarterectomy in symptomatic
patients: a randomised non-inferiority trial,
Lancet 2006; 368: 1239–47

11. SPACE
30 day results from the SPACE trial of stent-protected
angioplasty versus carotid endarterectomy in symptomatic
patients: a randomised non-inferiority trial,
Lancet 2006; 368: 1239–47

12. SPACE
30 day results from the SPACE trial of stent-protected
angioplasty versus carotid endarterectomy in symptomatic
patients: a randomised non-inferiority trial,
Lancet 2006; 368: 1239–47

13. SPACE
30 day results from the SPACE trial of stent-protected
angioplasty versus carotid endarterectomy in symptomatic
patients: a randomised non-inferiority trial,
Lancet 2006; 368: 1239–47

14. SPACE
30 day results from the SPACE trial of stent-protected
angioplasty versus carotid endarterectomy in symptomatic
patients: a randomised non-inferiority trial,
Lancet 2006; 368: 1239–47

15. SPACE
30 day results from the SPACE trial of stent-protected
angioplasty versus carotid endarterectomy in symptomatic
patients: a randomised non-inferiority trial,
Lancet 2006; 368: 1239–47

16. EVA -3S
Endarterectomy versus Stenting in Patients with
Symptomatic Severe Carotid Stenosis
N. Engl. J. Med 355:16
• multicenter
• non-inferiority randomized trial
• national research organisation
funding

17. EVA - 3S
Endarterectomy versus Stenting in Patients with Symptomatic Severe
Carotid Stenosis
N. Engl. J. Med 355:16

18. EVA - 3S
Endarterectomy versus Stenting in Patients with
Symptomatic Severe Carotid Stenosis
N. Engl. J. Med 355:16

19. EVA - 3S
Endarterectomy versus Stenting in Patients with
Symptomatic Severe Carotid Stenosis
N. Engl. J. Med 355:16

20. EVA - 3S
Endarterectomy versus Stenting in Patients with Symptomatic Severe
Carotid Stenosis
N. Engl. J. Med 355:16

21. EVA -3S
Support 1

22. EVA -3S
Support 2

23. Eva 3S - Support 3

24. Meta-analysis of Randomised Trials Comparing Carotid Endarterectomy
and Endovascular Treatment
Eur. J. Vasc. Endovasc. Surg, 34 470 -479(2007)
CEA vs. CAS

25. CREST
Carotid Revascularization Endarterectomy versus Stenting Trial:
Curr Control Trials Cardiovascular Med. 2001; 2(4): 160–164.

26. CREST
Carotid Revascularization Endarterectomy versus Stenting Trial:
Curr Control Trials Cardiovascular Med. 2001; 2(4): 160–164.

27. CREST
Carotid Revascularization Endarterectomy versus Stenting Trial
LEAD IN PHASE

28. CREST
• Summary

29. ACST-2
Asymptomatic Carotid Surgery Trial
A large, simple randomized trial to compare
carotid endarterectomy versus carotid artery stenting to prevent stroke

30. ACST-2
Asymptomatic Carotid
Surgery Trial A large, simple randomised trial to compare
carotid endarterectomy versus carotid artery stenting to prevent stroke

35. TACIT
Transatlantic Asymptomatic Carotid Intervention Trial

36. TACIT
Transatlantic Asymptomatic Carotid Intervention Trial

37. TACIT
Transatlantic Asymptomatic Carotid Intervention Trial

38. TACIT
Transatlantic Asymptomatic Carotid Intervention Trial

39. Critical Issue 1
Operator’s Experience

40. Critical Issue 1
Operator’s Experience

41. Critical Issue 2:
Octogenarians

42. Critical Issue 3:
Cognitive Changes
Cognitive Changes after Carotid Stenting
Cognitive Changes should be included
as End Points in all Clinical Trials

43. Critical Issue 4:
Protected VS. Unprotected CAS

44. Critical Issue 4:
Protected VS. Unprotected CAS

45. Critical Issue 5:
Heterogeneity of Clinical Trials

46. 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%
C
AB
ER
N
ET
(BSX
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SA
PPH
IR
E
(C
ordis)
M
A
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I&II(M
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AC
H
(BSX
)
C
R
EA
TE
Arm
2
(ev3/G
D
T)
M
A
VErIC
Int'l(M
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T)
C
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Arm
1
(ev3)
SE
C
uR
ITY
(ABT)
AR
C
H
eR
III(G
D
T)
AR
C
H
eR
II(G
D
T)

47. Critical issue 6:
Impacts after Space & Eva 3S

48. Critical issue 6:
Impacts after Space & Eva 3S

49. Critical issue 7:
Medical Therapy

55. CAS or CEA ?

61. Conclusion

62. Conclusions