Trials and Guidelines

Question 1

Name 3 guidelines that give recommendations on carotid stenting vs. endarterectomy. How are they the same? How do they differ?

Answer 1

1. AHA/ACC
2. SVS
3. ESC

Same: All state that CAS is preferred for symptomatic patients >70% who are anatomically or otherwise high risk for surgery

Differ: AHA/ACC states CAS is an alternative to CEA for symptomatic patients > 70% in centers with stroke/death rates of < 6%. SVS and ESC state CEA is preferred in these patients.

Question 2

*Name 8 trials comparing carotid stenting and endarterectomy and their conclusion with respect to inferiority of CAS

Answer 2

1) Leicester 1998: inferior
2. CAVATAS 2001: no difference
3. SAPPHIRE 2004/8: no difference
4. EVA-3S: inferior
5. SPACE 2006/8: no difference
6. Wallstent 2005: inferior
7. ICSS: Inferior 120d, no difference long term
8. CREST: no difference long term. periprocedural stroke superior. periprocedural MI inferior

Question 3

*Describe ICSS trial

Answer 3

CAS vs CEA

Pts: >1700, over 50% symptomatic carotid stenosis

Findings: 30 d risk of stroke was 2x with CAS (7 vs 3%)

4 y risk of nondisabling stroke higher with CAS (15 vs 9%)

No difference in long term disabling stroke.

Question 4

*Describe the SPACE trial

Answer 4

CAS vs CEA

Pts: 1200, > 70% symptomatic carotid stenosis

CEA and CAS no difference in stroke rate or death at 30d or 2y

Criticism: EPD only 27%

Question 5

*Describe the EVA 3S trial

Answer 5

CAS vs CEA

Pts: >500 pateintes, > 60% symptomatic carotid stenosis

CAS had significantly worse stroke/death

30 d: 9.6 vs 3.9

6 mo: 11.7 vs 6%

Stopped early due to high death rate in CAS

Criticism: operator heterogeneity

Question 6

*Describe the CREST trial

Answer 6

CAS vs CEA

Pts: 2500 symptomatic or asymptomatic > 70% stenosis with DUS or symptomatic >50% on angio

Roughly half were symptomatic and half were asymptomatic

No difference in stroke/MI/death or ipsilateral stroke

4 y: 7.2% vs 6.8%

10 y 11.8% vs 9.9%

CAS higher periprocedural stroke 4.1% vs 2.3%

CEA higher periprocedural MI 1.1% vs 2.3%

Question 7

Which trials showed worse results with CAS compared with CEA?

Answer 7

1. Leciester - CAS higher stroke rate
2. EVA-3S no difference in end point but higher restenosis rate
3. Wallstent
4. ICSS : 30d risk of stroke 2x with CAS, long term disabling stroke no difference

Question 8

Which trials comparing CAS and CEA have reported long term outcomes (10 y, 5 y)

Answer 8

10 y - CREST

5 y - ACT-1

(these are the only 2 listed on pg. 1231)