![Page 1: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/1.jpg)
The Interventional Perspective: Long Term Data on Carotid Stenting
Supports Its Efficacy In Stroke Prevention
Emerging And Novel Insights From CaRESS, SAPPHIRE. ARCHeR And Others
Subbarao Myla MD, FACC, FSCAIHoag Memorial Hospital Presbyterian
Newport Beach, CA, USA
![Page 2: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/2.jpg)
Disclosures
• Research Grant Support: Johnson & Johnson, Boston Scientific, Endotex, eV3, CR
Bard, Abbott, Lumen Bio
• Consultant, Scientific Advisory Board member Johnson & Johnson, Boston Scientific, Lumen Bio
• Stockholder Boston Scientific, Lumen Bio
![Page 3: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/3.jpg)
Objectives
• Is CAS Durable? In Stroke Prevention?
• Compared to what? CEA or Medical RX• In which patient groups?
In Maintaining Patency?• Restenosis• Role in stroke• Issues With Carotid Duplex
![Page 4: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/4.jpg)
![Page 5: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/5.jpg)
Historical, Randomized And Registry Trials
• Medical Therapy• NASCET. ACAS. • ECST. ACST• CAVATAS• SAPPHIRE, ARCHER. CaRESS• SPACE, EVA 3S• CREST lead In
![Page 6: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/6.jpg)
No Comparator For Medical Therapy In High Risk Patients
![Page 7: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/7.jpg)
![Page 8: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/8.jpg)
![Page 9: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/9.jpg)
![Page 10: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/10.jpg)
![Page 11: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/11.jpg)
Successful Technology Transfer with improving Learning Curve
![Page 12: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/12.jpg)
![Page 13: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/13.jpg)
![Page 14: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/14.jpg)
![Page 15: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/15.jpg)
![Page 16: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/16.jpg)
![Page 17: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/17.jpg)
Long Term Stroke Risk
![Page 18: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/18.jpg)
![Page 19: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/19.jpg)
SPACE
![Page 20: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/20.jpg)
![Page 21: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/21.jpg)
3.9
9.6
0
5
10
15
20
Primary Endpoint
30 d
ay d
eath
and
str
oke
(%)
CEA CAS
EVA-3S: Randomized CEA vs. CAS
RR 2.5 (95% CI, 1.2-5.1) P=0.01
262262 265265
Mas JL et al. New Engl J Med 2006;355:1661-71Mas JL et al. New Engl J Med 2006;355:1661-71
![Page 22: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/22.jpg)
EVA 3S Study
Mas JL et al, Lancet September 2008Mas JL et al, Lancet September 2008
![Page 23: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/23.jpg)
CARESS STUDY
• No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs.
• Interval CEA Stent P• 30 days 2.2% 2.0% NS• 4 yrs 9.6% 8.6% NS
JVS2005, C.Zarins TCT 2009 Oct 11th 2008
![Page 24: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/24.jpg)
![Page 25: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/25.jpg)
CREST RESTENOSIS
Helmut Lutsup for CREST Investigators 2007
![Page 26: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/26.jpg)
Helmut Lutsup for CREST Investigators 2007
CREST RESTENOSIS
![Page 27: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/27.jpg)
CREST RESTENOSIS
Helmut Lutsup for CREST Investigators 2007
![Page 28: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/28.jpg)
CARESS RESTENOSIS
• Baseline characteristics Impacting Restenosis.
• Restenosis as Inclusion Criteria CEA 11%CAS 36% P < 0.001
JVS2005, C.Zarins TCT 2009 Oct 11th 2008
![Page 29: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/29.jpg)
• 4 yr Restenosis by Duplex/ Angiography • Procedure CEA CAS P
Restenosis 5.9% 14.7% 0.01 Repeat Angio 5.1% 11.2% 0.05 TVR 2.18% 5.6% 0.26
• Hawthorne Effect• More angiography triggers more TVR• Duplex Criteria?
JVS2005, C. Zarins TCT 2009 Oct 11th 2008
CARESS RESTENOSIS
![Page 30: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/30.jpg)
• Restenosis by Duplex/ Angiography • Procedure I yr 4 yr
CEA 3.6% 5.9%CAS 6.3% 14.7%
P < 0.001
JVS2005, C. Zarins TCT 2009 Oct 11th 2008
CARESS RESTENOSIS
![Page 31: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/31.jpg)
Is Restenosis Stent Dependent?
![Page 32: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/32.jpg)
![Page 33: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/33.jpg)
New Criteria PSV >217cm/s or ICA/CCA Ratio >2.98 Predicts >50% Stenosis
![Page 34: The Interventional Perspective: Long ... - Neurovasc Exchange · CARESS STUDY • No difference in Any Stroke between Surgery or stent at 30 days or 4 yrs. • Interval CEA Stent](https://reader033.vdocuments.us/reader033/viewer/2022051408/600173e913985477981efc48/html5/thumbnails/34.jpg)
Conclusions
• CAS is a durable procedure in Stroke Prevention and maintaining Patency
• CAS Restenosis is a benign uncommon event.
• Carotid Duplex Criteria for CAS follow up need validation