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?
Registries & Clinical Trials
• CAVATAS • SAPHIRE• WALLSTENT• SPACE• EVA- 3S• CREST• ACST II, ACST I• ICSS• TACIT
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.
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.
SAPPHIREProtected carotid-artery stenting versus endarterectomy in high-risk patients.
N Engl J Med. 2004 Oct 7;351(15):1493-501.
SAPPHIREProtected carotid-artery stenting versus endarterectomy in high-risk patients.
N Engl J Med. 2004 Oct 7;351(15):1493-501.
SAPPHIREProtected carotid-artery stenting versus endarterectomy in high-risk patients.
N Engl J Med. 2004 Oct 7;351(15):1493-501.
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
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
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
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
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
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
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
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
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
EVA - 3SEndarterectomy versus Stenting in Patients with Symptomatic Severe
Carotid StenosisN. Engl. J. Med 355:16
EVA - 3SEndarterectomy versus Stenting in Patients with
Symptomatic Severe Carotid StenosisN. Engl. J. Med 355:16
EVA - 3SEndarterectomy versus Stenting in Patients with
Symptomatic Severe Carotid StenosisN. Engl. J. Med 355:16
EVA - 3SEndarterectomy versus Stenting in Patients with Symptomatic Severe
Carotid StenosisN. Engl. J. Med 355:16
EVA -3S Support 1
EVA -3S Support 2
Eva 3S - Support 3
Meta-analysis of Randomised Trials Comparing Carotid Endarterectomy and Endovascular Treatment
Eur. J. Vasc. Endovasc. Surg, 34 470 -479(2007) CEA vs. CAS
CREST Carotid Revascularization Endarterectomy versus Stenting Trial:
Curr Control Trials Cardiovascular Med. 2001; 2(4): 160–164.
CREST Carotid Revascularization Endarterectomy versus Stenting Trial:
Curr Control Trials Cardiovascular Med. 2001; 2(4): 160–164.
CREST Carotid Revascularization Endarterectomy versus Stenting Trial
LEAD IN PHASE
CREST
• Summary
ACST-2Asymptomatic Carotid Surgery Trial
A large, simple randomized trial to comparecarotid endarterectomy versus carotid artery stenting to prevent stroke
ACST-2Asymptomatic Carotid
Surgery Trial A large, simple randomised trial to comparecarotid endarterectomy versus carotid artery stenting to prevent stroke
TACIT Transatlantic Asymptomatic Carotid Intervention Trial
TACIT Transatlantic Asymptomatic Carotid Intervention Trial
TACIT Transatlantic Asymptomatic Carotid Intervention Trial
TACIT Transatlantic Asymptomatic Carotid Intervention Trial
Critical Issue 1Operator’s Experience
Critical Issue 1Operator’s Experience
Critical Issue 2:Octogenarians
Critical Issue 3:Cognitive Changes
Cognitive Changes after Carotid Stenting
Cognitive Changes should be included as End Points in all Clinical Trials
Critical Issue 4:Protected VS. Unprotected CAS
Critical Issue 4:Protected VS. Unprotected CAS
Critical Issue 5:Heterogeneity of Clinical Trials
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)
Critical issue 6: Impacts after Space & Eva 3S
Critical issue 6: Impacts after Space & Eva 3S
Critical issue 7: Medical Therapy
CAS or CEA ?
Conclusion
Conclusions
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