CAS vs CEA: How Would I Approach it

without a Regulatory Restriction?

LN Hopkins, MD
Elad Levy, MD
Adnan Siddiqui, MD, PhD
L. Nelson ‘Nick’ Hopkins, MD
I disclose the following financial relationship(s).
 Research Grant: Toshiba
 Speaker/Honoraria, Ownership Interest,
Consultant/Advisory Board: Boston Scientific
 Speaker/Honoraria: BARD, Cordis, SCAI
 Speaker/Honoraria, Consultant/Advisory Board: Abbott
 Consultant/Advisory Board: W. L. Gore
 Ownership Interest, Consultant/Advisory Board, Other-
Board Member: Micrus
 Ownership Interest, Other-Board Member:
AccessClosure
 Ownership Interest: Valor Medical
 LN Hopkins, MD
Personal Experience

• CEA > 2000

• CAS > 2000
• PI or Co PI or steering committee
• CREST, CARESS, ARCHeR, CAPTURE,
BEACH, CABANNA, CABERNET, SAPPHIRE,
VIVA, Act 1, EMPIRE, ARMOUR
 Carotid Angioplasty and Stenting:
Without Regulatory Restrictions

• Symptomatic >50% stenosis

• Asymptomatic
>70%, reasonable life expectancy
• Low risk CAS !!
• High risk for CEA
• Other
− Atheromatous Pseudo-occlusion
− Carotid Dissection
− Carotid Occlusion –acute stroke, sx ischemia
 Asymptomatic Patients
When Do We Treat?
• Life expectancy 5+ years
• Severe stenosis
− Low GSM, hemorrhagic plaque(MRI),
TCD activity MCA, ulcerative lesion
• Progression of plaque burden
• Evidence of flow restriction/poor perfusion
• Previous Cerebral Ischemia, ipsi or contralateral
• Fully informed patient
• No other more obvious source
 How to Treat
CEA vs CAS
• Risk Factor Analysis
− High risk CEA
− High risk CAS
• Evolution in
− Experience
− Technology
• Objective assessment of which procedure looks best for
each patient based on trial results and personal
experience
Predicting Stroke

WHO IS AT
GREATEST RISK??
Severity of Stenosis
Risk of Stroke

90-99% 26%
80-89% 18%
70-79% 12%

NASCET
 Severe Stenosis + Ulcer
STROKE RISK

95% - ulcer = 21% 2yr

95% + ulcer = 73% 2yr

NASCET
Intracranial Atherosclerotic Disease
+ Carotid Stenosis
Risk of Stroke

Medical Treatment
85-89% Increase
(3 year risk)
Ie.Poor Collateral

NASCET
 Age

Elderly Pts at Highest Risk for Stroke

CEA and CAS

Greatest Benefit in Elderly
 Elderly Patients
Risk of Stroke
70-99% Sten

Absolute Risk Reduction

Age <65 10%
Age 65-74 15%
Age >75 29%

NASCET
 Predicting Stroke

Some of the patients at

greatest risk for Stroke are
also at Increased Risk for
CEA
 NASCET / ACAS

CEA effectively reduces

stroke risk in Highly
Selected Patients
Who is at High Risk
for CEA??

CAS Not Yet Approved...

CEA is the ONLY Choice
CEA is Contraindicated
Medical Comorbidity

• Pre-op CABG
• Angina pectoris
• CHF
• Recent or evolving MI
• Renal failure
 CEA is Contraindicated
Surgical Contraindications

• Recurrent carotid stenosis

• Previous perilesional
- cervical surgery
• Contralateral laryngeal palsy
• Tracheostomy
• Post cervical XRT
Biller - Circ ‘98
 CEA is Contraindicated
Anatomical Contraindications
• Lesion above C2
• Lesion below clavicle
• ‘No neck’ / high bifurcation

- Common Sense
 CEA is Higher Risk
Poor Collateral

• Contralateral carotid occlusion

• Severe tandem intracranial
stenosis
• Multivessel occclusion

NASCET I & II
 Neurologic Instability
• Recurrent CVA
• Crescendo TIA
• Stroke in evolution
• Fluctuating neurologic deficit
• Intralumnal thrombus

• CEA risk - 14% Seiber, JNS

62 Year Old Male, Asx Carotid Stenosis
Father died of stroke at age 60
CEA or CAS ??

CAS Not YET Approved

 CAS Risk Factors
WHEN IS CAS High Risk
1. Sx (hot) lesion…
2. Elderly pts…
3. Low GSM…
4. Pre dil without EP …
5. Tortuousity- perilesional
6. Aortic Arch disease…
7. Multiple stents…
8. Duration Filter…
9. Concentric calcium…
10. Renal Failure...
Know who is high risk for stroke

Know who is high risk for CEA

Know who is high risk for CAS

Do what you would do for your Mom

Thank You!