CEA AND CAS

CEA AND CAS WHERE DOES THE TRUTH LIES? : 

CEA AND CAS WHERE DOES THE TRUTH LIES? Mr. Mohamed Omar El-Farok M.Sc , FRCS (Eng, Ed)

HOW TO SEARCH FOR EVIDENCE ? : 

HOW TO SEARCH FOR EVIDENCE ? Single center experience . Registries Randomized trials Meta-analysis recommendations AND Guidelines

Evan Esar (1899-1995) : 

Evan Esar (1899-1995) Statistics - the only science that enables different experts using the same figures to draw different conclusions

1- Single centre experience : : 

1- Single centre experience : Can go either ways Not accurate Usually biased Pushed by the industry in certain direction

2- Registries of CAS : 

2- Registries of CAS PRIAMUS Invatec D/S 4.5% MaVeriC Medtronic MAE 5.4% CREATE ( spider) MACE 5.6% MOMA Invatec MACE 5.7% SECuRITY Abbott D/S/MI 7.5% CREATE EV 3 MACE 6.3% • PASCAL Medtronic MAE 8% ARCHeR Abbott D/S/MI 8.3%

2-Capture : 

2-Capture US multicenter experience in CAS for high surgical risk patients WA Fray, J Yadav LN Hopkins et coll

2- CEA/CAS in USA 2003/2004 : 

2- CEA/CAS in USA 2003/2004 259080 Carotid Interventions Stroke Death CEA 0.88% 0.30% CAS 2.1% 1.3% MacPhee JT JVS 2007 P<0.0001

2- CEA/CAS in USA 2003/2004 : 

2- CEA/CAS in USA 2003/2004 Symptomatic (8%) Stroke Death CEA 1.1% 1% CAS 4.2% 17.5% P<0.0001

3-Randomized Trials : 

3-Randomized Trials

3- Risk of the procedures : 

3- Risk of the procedures Risks of the procedures 30-day risk S+D% In NEJM 2006

3- Space trial : 

3- Space trial 1183 patients CAS CEA Ipsilateal Stroke 6.68% 5.99% Death 0.67% 0.86% D+Sor Death 4.67% 3.77%

Severe stroke and death in EVA 3S and Space : 

Severe stroke and death in EVA 3S and Space EVA 3S SPACE CEA 1.5% 3.77% CAS 3.4% 4.77% P<0.001

3- Space : 

3- Space

3- SPACE : 

3- SPACE

Meta-analysis : 

Meta-analysis Cochrane Review 2007 Luebke et al EJVS 2007 Brahmanandam S J Vasc Surg 2007 Van de Waard Am J Surg 2008

Cochrane review : 

Cochrane review

Summary of meta-analysis : 

Summary of meta-analysis CAS = 7.8% CEA=5.9%

Are these data valid : 

Are these data valid Potential factors of adverse outcome with CAS Devices Cerebral protection devices Experience with CAS/CEA Disease

The stopped trial in Leister : 

The stopped trial in Leister What happened . The trial was stopped after 23 patients had been randomized to treatment. Only 17 of the randomized patients had received their allocated treatment at the time the trial was suspended. Ten carotid endarterectomies proceeded without complication, but 5 of the 7 patients who underwent stenting had a stroke. Three patients were excluded from the trial after randomization (1 patient occluded the carotid artery

Capture physician experience level : 

Capture physician experience level

5- Scientific Societies recommendations : 

5- Scientific Societies recommendations SVS : J Vasc Surg ( 48 ) 2008 480-6 In symptomatic patients > 50% stenosis we recommend carotid endarterectomy plus optimal medical therapy (GRADE 1 recommendation, high quality evidence). In high risk patients CAS is a potential alternative to carotid endarterectomy (GRADE 2 recommendation, low quality evidence).

5 -ESVS : 

5 -ESVS CAS should not be performed in symptomatic patients In high risk patients CAS may be used in high volume center Chris Liapis: EJVS to be published

So Why Dr Taher argue this evidence : 

So Why Dr Taher argue this evidence He is very skillful He has a very big practice He does not do CEA The thrill of investigation multiple studies Fame , a big star

Take home message : 

Take home message It is good if you can do CEA and CAS with the same skills The definite indication of each group is well known In the gray middle area where both can be done consider the one which carries the safest results in the current centre with the current setting Both procedures are here to stay Enjoy the debate

Thank you : 

Thank you