CAROTID STENTING WILL BECOME THE “GOLD STANDARD”

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					CAROTID STENTING WILL BECOME
   THE “GOLD STANDARD”


        Thomas J. Fogarty. M.D.
      Clinical Professor of Surgery
   Stanford University Medical Center
“DISEASES DESPERATE GROWN
   BY DESPERATE APPLIANCE
        ARE RELIEVED,
       OR NOT AT ALL”

 Hamlet, William Shakespeare
DR. GREENHALGH
IN INFANCY –

THE EMPEROR
NOW WEARS
CLOTHES !
THE “GOLD STANDARD” IS
   DETERMINED BY THE
AMOUNT YOU GET PAID ???
CAROTID STENTING WILL BECOME THE
CAROTID STENTING WILL BECOME THE
              “Gold Standard”
              “Gold Standard”
Utilized for;
1.    high risk patients with comorbidities
2.    patients with high lesions
3.    patients with restenosis after CEA
4.    patients with radiation induced stenosis
5.    decreasing anesthesia
     In addition : Non-surgeon specialists
          encouraging demand !!
CAROTID STENTING WILL BECOME THE
CAROTID STENTING WILL BECOME THE
           “Gold Standard”
           “Gold Standard”
Advantages over carotid endarterectomy
1. Less traumatic, less invasive
2.   Restenosis
3. Improved protection devices
4.   Net cost - $ device, drugs , but
     time procedure, hospitalization, recovery)
5.   Patient preference, acceptance
        CAROTID STENTING
        CAROTID STENTING
    RECENT PUBLISHED RESULTS
    RECENT PUBLISHED RESULTS
Authors   Yr.    Pt.#    Lesions   Success   30 day combined
                                              stroke mortality

Mathias 1999       633      799     99.0 %          3%
Bergeron 1999       99       99     97.0 %          1%
Wholey 2000       4757     5210     98.4 %          5.07 %
Dangas 2000        133      140     99.3 %          6.9 %
Roubin    2001     528      604     98.0 %          7.4 %

                Most cases performed without
                  use of protection devices
ONGOING MAJOR STROKE TRIALS(1)
ONGOING MAJOR STROKE TRIALS(1)

• CAVATAS Carotid and Vertebral Artery
  Transluminal Angioplasty Study
• CREST Carotid Revascularization
  Endarterectomy Versus Stenting Trial
• Global Carotid Artery Stent Registry –
  Evaluate growth of carotid stent placement &
  early review of results, procedures, tech.
  success, types stents, complications, & long
  term FU for restenosis & neuro events.
 ONGOING MAJOR STROKE TRIALS (2)

• ICSS International Carotid Stenting Study
• SPACE Stent Protected Percutaneous
  Angioplasty of the Carotid Versus
  Endarterectomy
• CARESS Carotid Revascularization with
  Endarterectomy or Stenting Systems

Extensive trials will ultimately determine
     “gold standard” utilization !
CAROTID STENTING WILL BECOME THE
CAROTID STENTING WILL BECOME THE
          “Gold Standard”
          “Gold Standard”
 In Conclusion
 • CAS Results continue to improve
 • Selected patients can be treated with CAS
   with periprocedural complications similar
   to CEA
 • Technology continues to improve
 • Distal protection devices decrease number
   of microemboli
 • Patients will demand less invasive
   procedure
EVEN OLD FOLKS,
DR GREENHALGH,
CAN LEARN HOW
TO USE NEW
FANGLED
DEVICES
EFFECTIVELY
AND
SUCCESSFULLY !!