CAS vs CEA Study CAS CEA Leicester 1998

Συμπτωματικοί ασθενείς: CAS vs CEA Μετα-ανάλυση: ΑΕΕ ή θάνατος στον πρώτο μήνα Study CAS CEA Leicester, 1998 5/11 0/12 Wallstent, 2001 13/107 5/112 Kentucky, 2001 0/53 1/51 CAVATAS, 2001 22/221 23/231 SAPPHIRE, 2004 0/50 3/46 EVA-3 S, 2006 25/265 10/262 SPACE, 2006 46/599 38/584 0/10 1/10 ICSS, 2010 72/853 40/857 CREST, 2010 40/668 21/653 223/2837 142/2818 BACASS, 2008 Total Test for heterogeneity Q-value=15. 42, df=9, P=0. 08, I 2=41. 6% 0. 01 0. 1 Favours CAS 1 10 Favours CEA Kakisis J, Liapis C. Eur J Vasc Endovasc Surg 2012; 44: 238 -43. 100 OR (95% CI) P 21. 15 (1. 01 -445. 00) 0. 05 2. 96 (1. 02 -8. 61) 0. 046 0. 31 (1. 25 -7. 90) 0. 48 1. 0 (0. 54 -1. 85) 1. 0 0. 12 (6. 18 -2. 45) 0. 17 2. 62 (1. 23 -5. 58) 0. 01 1. 20 (0. 77 -1. 87) 0. 43 0. 30 (0. 01 -8. 33) 0. 48 1. 88 (1. 26 -2. 81) 0. 002 1. 92 (1. 12 -3. 29) 0. 02 1. 61 (1. 14 -2. 28) 0. 007

Ασυμπτωματικοί ασθενείς: CAS vs CEA Μετα-ανάλυση: ΑΕΕ ή θάνατος στον πρώτο μήνα Study CAS CEA OR (95% CI) P CAVATAS, 2001 3/30 2/22 1. 11 (0. 17 -7. 28) 0. 91 SAPPHIRE, 2004 8/117 6/120 1. 39 (0. 47 -4. 15) 0. 55 Kentucky, 2004 0/43 0/42 Not estimable CREST, 2010 15/594 8/587 1. 88 (0. 79 -4. 46) 0. 15 Total 26/784 16/771 1. 60 (0. 84 -3. 02) 0. 15 Test for heterogeneity Q-value=0. 33, df=2, P=0. 8, I 2=0% 0. 01 0. 1 Favours CAS 1 10 100 Favours CEA Kakisis J, Liapis C. Eur J Vasc Endovasc Surg 2012; 44: 238 -43.

The post-RCTs era: ESVS, Australian and SVS guidelines

The Arch

1. Διαμόρφωση αορτικού τόξου Φυσιολογική παραλλαγή 70% Bovine Variety 27% LCCA from the Innominate Common arch origin of LCCA & Innominate Left Vertebral Originating from the Arch 0. 05%

Η γωνίωση του αορτικού τόξου προβλέπει νευρολογικές επιπλοκές και τεχνικές αποτυχίες… Variable Total Stroke / (%) TIA (%) Aortic Arch III & Bovine 20. 5 11. 5 I & II 79. 5 6. 7 Proximal Tortuosity Ix >150 29. 5 13. 6 <150 5. 2 70. 5 p NS Technical failures (%) 21. 1 p <0. 001 5. 5 0. 023 14. 8 6. 2 Faggioly G, et al. J Vasc Surg 2007; 46: 1119 -24 0. 014

Οι μετά-CAS MRI βλάβες είναι συνδεδεμένες με το πολυσύνθετο αορτικό τόξο Variable Difficult arch or complicated aortic plaque or TI>150 Simple arch or uncomplicated aortic plaque or TI<150 Total Volume (mm 3) Volume, ipsilateral lesions (mm 3) Volume, NON IPSILATERAL lesions (mm 3) 564 (570) 31. 2 (352) 0 (117) 0 (172) 0. 018 0. 9 564 (687) 0 (133) 0. 001 Faggioly G, et al. J Vasc Surg 2009; 49: 80 -5 p

CAS σε Υπερήλικες The CREST Study

CAS σε Υπερήλικες CAPTURE 2 (5297 patients) Chaturvedi S, et al. Stroke 2010

CAS σε Υπερήλικες EVA 3 s, SPACE & ICSS Metaanalysis (3433 patients) Bonati LH, et al. Lancet 2010

X X τύπος III Ασβέστωση αορτικού τόξου X ICA ελίκωση X Στένωση έκφυσης CAS δεν ενδείκνυται Liapis et al. Aortic arch: markers, imaging and procedure planning for carotid intervention. Vasc Dis Manag 2009

Results of carotid artery stenting with transcervical access Conclusions: CAS with the transcervical approach is a safe procedure with low incidence of stroke and complications. It can be used as an alternative to femoral access in patients with unfavorable aortoiliac or aortic arch anatomy. Sfyroeras G. , Liapis C. et. al J Vasc Surg 2013; 58: 1402 -7 Winona W. Wu et. al J Vasc Surg 2019 In Press

Τυχαιοποιημένες μελέτες για την αντιμετώπιση της καρωτιδικής νόσου • • • VA, 1991 ACAS, 1995 NASCET, 1998 ECST, 1998 ACST, 2004 • • Leicester, 1998 • Wallstent, 2001 • Kentucky, 2001 • CAVATAS, 2001 • SAPPHIRE, 2004 • vs EVA-3 S, 2006 SPACE, 2006 BACASS, 2008 ICSS, 2010 CREST, 2010 -16 CREST 2, 2016 -20 ACT 1, 2016 vs

Το ΟΕΜ συσχετίζεται με αυξημένη θνητότητα? Standard error ? ? CREST. Circulation 2011, 123: 2571 -2578

Long-Term Results of Stenting versus Endarterectomy for Carotid-Artery Stenosis (CREST) The 10 -year rate of ipsilateral stroke was 6. 9 % (0. 7 % per year) for CAS, and 5. 6 % (0. 6 % per year) for endarterectomy. The rates of postprocedural ipsilateral stroke and all postprocedural stroke were strikingly similar in asymptomatic and symptomatic patients at 5 and at 10 years T. G. Brott et. al. NEJM Feb. 2016

Patient clinical status and outcomes of carotid artery stenting : The German mandatory registry Kallmayer et. al J. Cardiovasc. Surg. (2015)

Stroke/death rates for “average risk” asymptomatic patients undergoing CAS and CEA in registries K. I Paraskevas, E. L Kalmykov, A. R. Naylor Eur J Vasc Endovasc Surg (2015) 1 -10

Stroke/death rates for “average risk” symptomatic patients undergoing CAS and CEA in registries K. I Paraskevas, E. L Kalmykov, A. R. Naylor Eur J Vasc Endovasc Surg (2015) 1 -10

RCTs που διεξάγονται Carotid Endarterectomy Versus Carotid Artery Stenting in Asymptomatic Patients (ACST-2) Ιαν 2008 – Ιαν 2018 5000 ασθενείς CAS vs. CEA Stent-protected Angioplasty in Asymptomatic Carotid Artery Stenosis vs. Endarterectomy (SPACE 2) - STOPPED Μαρ 2009 – Ιούλ 2015 3640 ασθενείς CAS vs. CEA vs. BMT European Carotid Surgery Trial 2 (ECST-2) Μαρ 2012 – Ιούλ 2022 2000 ασθενείς CAS/CEA vs. BMT Carotid Revascularization Endarterectomy versus Stenting Trial (CREST-2) 2014 - 2400 ασθενείς CAS/BMT vs. CEA/BMT vs. BMT

ESVS Guidelines 2017