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When is Carotid
Endarterectomy Preferable
to Carotid Stenting?
William Pevec, MD Professor and Chief
Division of Endovascular and Vascular Surgery
UC Davis School of Medicine
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• No significant financial relationships exist
between the topics in this presentation and
the speaker
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Pathophysiology of Stroke
• Emboli from unstable carotid plaque.
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Pathophysiology of Stroke
• Emboli from unstable carotid plaque.
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Purpose of arterial stenting
• Increase lumen
– Rarely are strokes due to hemodynamic effect
of carotid stenosis
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Purpose of arterial stenting
• Increase lumen
– Rarely are strokes due to hemodynamic effect
of carotid stenosis
• Stenting is not logical in carotid disease
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SAPPHIRE (Yadav, NEJM 2004; 351:1493-501)
• Symptomatic stenosis > 50%
• Asymptomatic stenosis > 80%
• “High risk”: – Significant cardiac disease
– Severe pulmonary disease
– Contralateral carotid occlusion
– Recurrent carotid stenosis
– Age > 80 years
– Prior RND or radiation of neck
– Contralateral laryngeal nerve palsy
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SAPPHIRE
• 334 patients randomized : – Carotid Endarterectomy
– Carotid Stenting
• 30 day Stroke or Death:
–Stent 4.8%
–Endarterectomy 5.6%
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Outcome at 3 years (Gurm, NEJM 2008; 358:1572-9)
Stent CEA p
Death 18.6% 21.0% 0.68
MI 5.4% 8.4% 0.39
Stroke 9.0% 9.0% 0.99
Stroke, MI,
or Death
24.6% 26.9% 0.71
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Market Assessment,
circa 2005 • 75% of carotid procedures would be stents
CEA
CAS
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SPACE (Lancet Neurology 2008; 7:893-902)
• Symptomatic carotid stenosis > 70%
• Randomized, stent vs. endarterectomy
• 1,214 patients
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SPACE
Outcome at 2 years
Stent CEA HR
Any Stroke 10.9% 10.1% 1.10
Any Death 6.3% 5.0% 1.11
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EVA-3S (NEJM 2006; 355:1660-71)
• Symptomatic carotid stenosis > 60%
• Randomized, stent vs. endarterectomy
• 520 patients
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EVA-3S
Outcome at 30 days
Stent CEA p
Death 0.8% 1.2% 0.68
MI 0.4% 0.8% 0.62
Nonfatal
Stroke
8.8% 2.7% 0.004
Stroke or
Death
9.6% 3.9% 0.01
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Ipsilateral stroke Any stroke Any stroke/death
EVA-3S at Four Years
Lancet 2008; 7:885-92
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ICSS (Lancet 2010;375:985-997)
• Symptoms within 12 months – 95% had symptoms within 6 months
• > 50% stenosis – 90% had > 70% stenosis
• Eligible for CAS or CEA
• 1713 patients
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ICSS (Lancet 2010;375:985-997)
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For patients with symptomatic carotid disease,
endarterectomy is safer than stenting
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What about
asymptomatic
patients?
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CREST (Brott NEJM 2010; 363:11-23)
• NIH sponsored
• “Conventional risk” patients
• Randomized, CEA vs CAS with EPD
– Symptomatic > 50%
– Asymptomatic > 70%
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Periprocedure Stroke or Death, or
Late Ipsilateral Stroke
CAS CEA P CAS CEA P
Asymptomatic 2.5% 1.4% 0.15 4.5% 2.7% 0.07
Symptomatic 6.0% 3.2% 0.02 8.0% 6.4% 0.14
30 days 4 years
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CEA vs CAS
Asymptomatic Patients J Vasc Surg 2013;57:627-34
• CA hospital discharge data, 2005-09
– CEA 36,524
– CAS 6053
Peri-op Stroke or Death p
CEA 1.8 <0.001
CAS 4.1
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Effect of Age
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Effect of Age
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CREST 30 Day Outcomes, Stenting
Based on Age
> 80 yo (%)
n = 99
< 80 yo (%)
n = 650
P
Death 2.0 0.6 0.14
Stroke 12.1 2.8 <0.0001
Death or Stroke 12.1 3.2 <0.0001
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SVS Registry,
J Vasc Surg 2012;55:1313-21
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SVS Registry,
J Vasc Surg 2012;55:1313-21
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SVS Registry,
J Vasc Surg 2012;55:1313-21
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What about the
“Real World”
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0%
2%
4%
6%
8%
10%
12%
Stroke/MI/Death Stroke
Asymptomatic (n=3,018) Symptomatic (n=233)
Death MI
ACAS
NASCET
5.4
12.0
1.3
4.8 4.1
8.9
0.8 1.7
CAPTURE 30 day procedural risk
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What about those increased
myocardial infarctions?
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Kaplan-Meier survival curves after randomized carotid revascularization in the Carotid
Revascularization Endarterectomy Versus Stenting Trial (CREST).
Blackshear J L et al. Circulation 2011;123:2571-2578
Copyright © American Heart Association
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CREST
• Mortality at 4 years, any stroke: 20%
– 2x mortality for those without stroke
• Stroke rate was 2x higher with CAS vs CEA
– Negates the advantage of fewer MI
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(Oxford neurologist)
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When is Carotid Endarterectomy
Preferable to Carotid Stenting?
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When is Carotid Endarterectomy
Preferable to Carotid Stenting?
• Symptomatic patients
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When is Carotid Endarterectomy
Preferable to Carotid Stenting?
• Symptomatic patients
• Asymptomatic patients
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When is Carotid Endarterectomy
Preferable to Carotid Stenting?
• Symptomatic patients
• Asymptomatic patients
• Patients over the age of 65
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When is Carotid Stenting Preferable
to Carotid Endarterctomy?
• Anatomic reasons:
–Prior neck radiation
–Prior neck dissection
–Tracheostomy
–Recurrent stenosis
–High bifurcation
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• Thank you, Dr. Southard