1. Carotid Artery Stenosis: Stenting vs. Endarterectomy Városmajor Study. L. Entz,, E.Dósa, K. Hüttl. Department of Cardiovascular Surgery, Semmelweis University, Budapest, Hungary Oxford,ACST-2 2014

2. Conflict of Interest None

3. Introduction Clinical Trials:CEA vs. CAS CAVATAS CAVATAS Very high perioperative stroke/morbidity/mortality for both CEA (9,9%) and CAS (26%)Very high perioperative stroke/morbidity/mortality for both CEA (9,9%) and CAS (26%) Protection device: 0Protection device: 0 Recurrent stenosis rate: 22%Recurrent stenosis rate: 22% SAPPHIRE: SAPPHIRE: high risk patients onlyhigh risk patients only funded by industry (protection devices, stents)funded by industry (protection devices, stents)

4. Clinical Trials CEA vs. CAS SPACE: SPACE: Protection device was obligatoryProtection device was obligatory 30-day death/stroke rate: CEA/CAS: 6.3%/6.8% p=NS30-day death/stroke rate: CEA/CAS: 6.3%/6.8% p=NS Non-inferiority was not prooven p=0.9 NSNon-inferiority was not prooven p=0.9 NS StoppedStopped EVA-3S: EVA-3S: 527 patients, death/stroke rate:527 patients, death/stroke rate: CEA/CAS: 3,9%/9,6% (p<.05) CEA/CAS: 3,9%/9,6% (p<.05) StoppedStopped

5. Clinical Trials CEA vs. CAS ICSS: ICSS: 1713 symptomatic patients CEA CAS 1713 symptomatic patients CEA CAS Stroke, MI, death rate: 4,0%.vs. 7.4% (p<.006)Stroke, MI, death rate: 4,0%.vs. 7.4% (p<.006) stroke alone: 3.3%vs.7.0% stroke alone: 3.3%vs.7.0% MRI Substudy: new ischemic lesions MRI Substudy: new ischemic lesions CEA/CAS: 13/50 p=0.001 CEA/CAS: 13/50 p=0.001 4-6 weeks later : 8%/30% 4-6 weeks later : 8%/30% CREST:CREST: 2502 asympt. And sympt.patients CEA CAS2502 asympt. And sympt.patients CEA CAS Stroke, MI, death rate: 4.5% vs.5.2% NSStroke, MI, death rate: 4.5% vs.5.2% NS stroke alone: 2.3%vs.4.1% stroke alone: 2.3%vs.4.1%

6. Results of the study on postoperative intracranial hemorrhage (ICH) in cases of CEA/CAS in USA Timaran et al. J Vasc Surg 2009:49.(3):623-8 The Nationwide Inpatient Sample was used for the year 2005 The Nationwide Inpatient Sample was used for the year 2005 135,093 patients were revascularized, 90,4% CEA, 9,6%CAS 135,093 patients were revascularized, 90,4% CEA, 9,6%CAS Postop.stroke rate: CEA 1,1% CAS: 2.1% p<0.001 Postop.stroke rate: CEA 1,1% CAS: 2.1% p<0.001 In-hosp. Mortality: CEA 0.6% CAS: 1.1% p<0.001 In-hosp. Mortality: CEA 0.6% CAS: 1.1% p<0.001 ICH CEA 0.016% CAS: 0.15% p<0.001 ICH CEA 0.016% CAS: 0.15% p<0.001 Conclusion: CAS was an independent predictor for: Conclusion: CAS was an independent predictor for: postop. stroke (OR:1.77) postop. stroke (OR:1.77) in-hosp. mortality (OR:1.49) in-hosp. mortality (OR:1.49) ICH (OR: 5.9 ) ICH (OR: 5.9 )

7. CEA/CAS Experience at Varosmajor Clinic 01.01.2003-12.31.2008 Limitations: Retrospective study Retrospective study Only in-hospital stroke/morbidity/mortality Only in-hospital stroke/morbidity/mortality There is a significant difference between the two groups in the number of symptomatic patients There is a significant difference between the two groups in the number of symptomatic patientsHowever: the results are satisfactory large number of cases on both sides

8. Clinical Data N=3974 CEA=2509 P M:1455(58%) M:1455(58%) F :1054(42%) F :1054(42%) Mean age: 66.9 years (20-90) Mean age: 66.9 years (20-90) CAS=1465 P M:921(62,8%) M:921(62,8%) F :544(37,2%) F :544(37,2%) Mean age: 66.9 years (39-91) Mean age: 66.9 years (39-91)

9. CAROTID CEA + CAS

10. Clinical Presentation Clinical Presentation CEA Asymptomatic Asymptomatic St. I+ IIb 1581 Pts.(63%) St. I+ IIb 1581 Pts.(63%) Symptomatic IIa-IV.b. 928 Pts..(37%) Symptomatic IIa-IV.b. 928 Pts..(37%) CAS Asymptomatic Asymptomatic St. I+ IIb 1106 Pts. (75,5%) St. I+ IIb 1106 Pts. (75,5%) Symptomatic 359 Pts. (24,5%) Symptomatic 359 Pts. (24,5%) P<0,00001

11. Surgical Technique Eversion Endarterectomy Eversion Endarterectomy > 95%> 95% Without shunt> 95%

12. CAS Protection device(100%) Protection device(100%) Type of stent Type of stent WallstentWallstent PrecisePrecise NextstentNextstent

13. Indication for surgery/stenting Based on the results of : NASCET Based on the results of : NASCET ECST ECST ACST ACST

14. High risk patients and high anatomic risk indications for CAS High risk patients and high anatomic risk indications for CAS restenosis restenosis high localization of stenosis. high localization of stenosis. after irradiation after irradiation previous surgery on the neck previous surgery on the neck high risk patients high risk patients

15. Contraindications to CAS Severe calcification Severe calcification Coiling Coiling High risk of embolization based on US/CT High risk of embolization based on US/CT

16. CEACAS TIA30(1,2%)123(8,4%)p<0.00001! Mortality12(0.48%)5(0.34%)p=0,523 Minor Stroke 26(1,04%)17(1.16%)p=0,715 Major Stroke 39(1.55%)12(0,82%)p=0,047! PSMM(3,3%)(2,25%)p=0,057! Postoperative complications Postoperative complications

17. Major stroke rate of symptomatic patients Preop. stages Postop. stroke strokeCEAPostop. CAS I.422.09%252.25% IIa-IV232,47%41.4%p=0,136

18. There is a significant difference in favor of CEA vs. CAS in postoperative TIA-rates There is a significant difference in favor of CEA vs. CAS in postoperative TIA-rates Both procedures have Low PSMM rates Both procedures have Low PSMM rates CAS can be performed by experienced operators in high volume center CAS can be performed by experienced operators in high volume center Conclusions

19. PERSPECKTIVES? CEA+CAS

23. Thank you…

24. ..for your attention!!