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L. Entz ,, E.Dósa , K. Hüttl .

L. Entz ,, E.Dósa , K. Hüttl .

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L. Entz ,, E.Dósa , K. Hüttl .

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  1. CarotidArteryStenosis:Stenting vs. EndarterectomyVárosmajor Study. L. Entz,, E.Dósa, K. Hüttl. Department of Cardiovascular Surgery, Semmelweis University, Budapest, Hungary Oxford,ACST-2 2014

  2. Conflict of Interest None

  3. IntroductionClinical Trials:CEA vs. CAS • CAVATAS • Very highperioperative stroke/morbidity/mortalityforboth CEA (9,9%)and CAS (26%) • Protectiondevice: 0 • Recurrentstenosisrate: 22% • SAPPHIRE: • highriskpatientsonly • fundedbyindustry (protectiondevices, stents)

  4. Clinical Trials CEA vs. CAS • SPACE: • Protectiondevicewasobligatory • 30-day death/stroke rate: CEA/CAS: 6.3%/6.8% p=NS • Non-inferioritywasnotprooven p=0.9 NS • Stopped • EVA-3S: • 527 patients, death/stroke rate: • CEA/CAS: 3,9%/9,6% (p<.05) • Stopped

  5. Clinical Trials CEA vs. CAS • ICSS: • 1713 symptomaticpatientsCEA CAS • Stroke, MI, deathrate: 4,0%.vs. 7.4%(p<.006) • stroke alone: 3.3%vs.7.0% • MRI Substudy: newischemiclesions • CEA/CAS: 13/50 p=0.001 • 4-6 weekslater : 8%/30% • CREST: • 2502 asympt. And sympt.patientsCEA CAS • Stroke, MI, deathrate: 4.5% vs.5.2% NS • stroke alone: 2.3%vs.4.1%

  6. Results of the study on postoperative intracranial hemorrhage (ICH) in cases of CEA/CAS in USATimaran et al. J Vasc Surg 2009:49.(3):623-8 • The NationwideInpatientSamplewasusedfortheyear 2005 • 135,093 patientswererevascularized, 90,4% CEA, 9,6%CAS • Postop.strokerate: CEA 1,1% CAS: 2.1% p<0.001 • In-hosp. Mortality: CEA 0.6% CAS: 1.1% p<0.001 • ICH CEA 0.016% CAS: 0.15% p<0.001 • Conclusion: CAS was an independentpredictorfor: • postop. stroke (OR:1.77) • in-hosp. mortality (OR:1.49) • ICH (OR: 5.9 )

  7. CEA/CAS Experience at Varosmajor Clinic01.01.2003-12.31.2008 Limitations: Retrospectivestudy Only in-hospital stroke/morbidity/mortality There is a significantdifferencebetweenthetwogroupsinthenumber of symptomaticpatients However: theresultsaresatisfactory largenumber of casesonbothsides

  8. CEA=2509 P M: 1455(58%) F : 1054(42%) Mean age: 66.9 years (20-90) CAS=1465 P M: 921(62,8%) F : 544(37,2%) Mean age: 66.9 years (39-91) Clinical DataN=3974

  9. CAROTID CEA + CAS

  10. CEA Asymptomatic St. I+ IIb 1581 Pts.(63%) SymptomaticIIa-IV.b. 928 Pts..(37%) CAS Asymptomatic St. I+ IIb1106 Pts. (75,5%) Symptomatic359 Pts. (24,5%) Clinical Presentation P<0,00001 P<0,00001

  11. Surgical Technique • Eversion Endarterectomy • > 95% Without shunt> 95%

  12. Protection device(100%) Type of stent Wallstent Precise Nextstent CAS

  13. Indication for surgery/stenting • Based on the results of : NASCET • ECST • ACST

  14. High risk patients and high anatomic risk indications for CAS • restenosis • highlocalization of stenosis. • after irradiation • previoussurgeryontheneck • highriskpatients

  15. Contraindications to CAS • Severecalcification • Coiling • Highriskofembolizationbasedon US/CT

  16. Postoperative complications

  17. Major stroke rate of symptomatic patients

  18. Conclusions • There is a significantdifferenceinfavor of CEA vs. CAS inpostoperativeTIA-rates • Both procedures have Low PSMM rates • CAS can be performedby experienced operatorsinhighvolume center

  19. PERSPECKTIVES? CEA + CAS

  20. Thank you…

  21. ..for your attention!!