How to Stent a Carotid, How Not, and When to Say No

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  • 11. Hobson RW II, Weiss DG, Fields WS, et a1. Efficacyof carotid endanerectomy for asymptomatic carotidstenosis. The Veterans Affairs Cooperative StudyGroup. N Engl J Med 1993;328:221-227.

    12. The CASANOVA Stlldy Group. Carotid surgery ver-sus medical therapy in asymptomatic carotid steno-sis. Stroke 1991;22:1229-1235

    13. Mayo Asymptomatic Carotid Endanerectomy StudyGroup. Results of a randomized controlled trial ofcarotid endarterectomy for asymptomatic carotidstenosis. Mayo Clin Proc 1992;67:513-518.

    14. Perry JR, Szalai JP, Norris jW. Consensus againstboth endarterectomy and routine screening forasymptomatic carotid artery stenosis. CanadianStroke Consortium. Arch Neurol 1996;54:25-28

    15. Chaturvedi S, Halliday A. Is another clinical trialwarranted regarding endarterectomy for asymptom-atic carotid stenosis? Cerebrovasc Dis 1998;8:210-213.

    16. Barnett Hj, Taylor DW, Eliasziw M, et al. Benefit ofcarotid endarterectomy in patients with symptomaticmoderate or severe stenosis. N Engl j Med 1998;339:1468-1471.

    17. Wennberg DE, Lucas FL, Birkmeyer jD, BredenbergCE, Fisher ES. Variation in carotid endarterectomymortality in the Medicare population: Trial hospitals,volume, and patient characteristics. JAMA 1998;279:1278-1281.

    12:50 p.m.

    Global Results of Carotid Stenting TrialsMichael H. Wholey, MDUniversity of Texas Health Science Center at San AntonioSan Antonio, Texas

    PurposeTo review and update the current status of carotid arterystent placement in the world.

    MethodsSurveys to major interventionaJ centers in Europe, Northand South America and Asia were initially completed inJune 1997. Subsequent information from these 24 centersin addition to 19 new centers have been obtained toupdate the information.

    ResultsThe total number of endovascular carotid stent proce-dures that have been performed worldwide to date in-cluded 6,734 procedures involVing 6,327 patients. Therewas a technical success of 98.4% with 6,635 carotidarteries treated. Complications that occurred during thecarotid stent placement or within a thirty day periodfollowing placement were recorded. Overall, there were168 Transient Ischemic Attacks (TIAs) for a rate of 2.50%.Based on the total patient population, there were 182minor strokes with a rate of occurrence of 2.70%. Thetotal number of major strokes was 91 for a rate of 1.35%.

    There were 51 deaths within a 30-day post procedureperiod resulting in a mortality rate of 0.76%. The com-bined minor and major strokes and procedure-relateddeath rate was 4.810/0. Restenosis rates of carotid stentinghave been 5.56% at 12 months. The rate of neurologicevents post stent placement has been 1.25% at 12months follow up.

    In a subset of 11 centers involving 2,038 cases, em-bolic protective devices were found to have decreased thestroke and procedure-death rate from 4.1% unprotected to2.4% protected. In a similar subset study, 24 centers with4,200 cases, responded that stroke and procedure relateddeath rate was 5.9% in symptomatic populations and 2.9%in asymptomatic populations respectively.

    ConclusionsEndovascular stent treatment of carotid artery atheroscle-rotic disease is growing as an alternative for vascularsurgery especially for patients that are at high risk forstandard carotid endarterectomy. The periproceduralrisks for major and minor strokes and death are generallyacceptable at this early stage of development and havenot changed significantly since the first survey results.

    1:10 p.m.

    How to Stent a Carotid, How Not, and When toSay NoLee R. Guterman, MDUniverity ofBuffalO-Millard Fillmore HospitalBuffalo, New York

    1:40 p.m.

    On-Going Carotid Stent Registries and TrialsSriram S. [yer, MDLenox Hill HospitalNew York, New York

    2:00 p.m.

    PANEL DISCUSSIONCarotid Stent Reimbursement and How toParticipate in a Trial

    Panelists: ].]. "Buddy" Connors, III, MDLee R. Guterman, MDSriram S. Iyer, MDMichael H. Wholey, MD

    Dialysis Interventions I ':

    Sunday, April 7, 20023:15 p.m.-4:45 p.m.Coordinator/Moderator; Anne C. Roberts, MD

    Objectives:Upon completion of this course, the attendeeshould be able to:1. Explain how grafts and fistulas are placed surgi-

    cally, and the surgical options for revising them.P183