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Journal Review in Vascular Surgery: Carotid Revascularization – CEA, Stent or Nothing at All? · Behind The Knife: The Surgery Podcast

• Carotid Revascularization- CEA, stent or nothing at all_ === [00:00:00] Hello everyone, and welcome back to another episode of Behind the Knife. My name is Christian Hadid and today we'll be discussing carotid disease. We have four landmark trials to discuss, and by the end of this you'll be better able to answer the questions of who should get a carotid endarterectomy, who should get a stent, and who should just be managed medically. To help us answer these questions we have with us, Dr. Flores, Dr. Hazer, and Dr. Harrington from the Brookdale Vascular Surgery team. With their different levels of experience. We'll, not only examine the landmark trials, but also how they apply the data in real world practice today. These studies gave us clear answers in some places and a lot of gray zones in others. That's where our discussion is going to get interesting. Welcome everyone. Thanks for that warm welcome, Christian. We're excited to be here today. Before we dive into the papers, I think it's helpful to prime everyone on carotid disease and how they should be thinking about the data. When trying to decide what intervention's best for your patient, the key is to [00:01:00] group patients into two major categories, symptomatic or asymptomatic. Then break them down further by the degree of credit stenosis, whether it's high grade, over 70%, moderate 50 to 69%, or mild stenosis, which is considered less than 50%. And of course, every patient's individual risk profile matters. This framework helps us to group and interpret the data. Yeah, so it's really about symptoms and then degrees of stenosis. Thanks, Dr. Hazer. That's a great way to kind of organize our thinking and quickly figure out which patients will clearly benefit and those who clearly won't. With that, let's dive into our first paper, which showed that surgery is clearly beneficial for some patients. The North American symptomatic Carotid Endarterectomy trial or NASA published in 1991, this was a randomized controlled trial that clearly showed benefit with surgery for patients with high grade symptomatic stenosis. Over 600 patients with recent TIA or stroke that is [00:02:00] symptomatic. Were randomized to CEA plus medical therapy versus medical therapy alone. Patients were stratified by the degree of stenosis, 70 to 99% versus 30 to 69%. All of the patients were then followed by a neurologist at 30 days post-op, and then about every three to four months or so to evaluate for stroke or death. So what was really interesting about this trial was that the investigators actually stopped randomizing patients with high grade stenosis as endarterectomy showed a clear benefit over medical therapy in this patient group. Now at 30 days surgery did carry a bit more upfront risk of major stroke or death, about 2.1% versus 1.2% with medical therapy. I mean, that's not too surprising since you're adding the risks of an operation. But at two years, the CEA group had a much lower risk of any stroke, and that was 9% versus 26% in the medical therapy only group. That gives us an absolute risk reduction of about 17%. Importantly, the benefits of CEA increased with the [00:03:00] higher degrees of stenosis without an increase in complications. With that, I'll ask the group, how did NASA shape the way you approach symptomatic carotid disease in practice today? Well, Christian, I was five years old when that study came out, so it didn't really have a big impact on my practice at the time. Yeah. But it definitely affected the way my parents practiced. I would like to hear what Dr. Flores and Dr. Hazer think, and then I can share my thoughts. There is no question that this study changed the way they used to practice many years ago. We used to be a lot more aggressive in treated carotid artery disease with otin atherectomy. The critical stenosis was somewhat lower in range, and we used to do surgery for those patients, and that was considered acceptable. We become more selective in doing otin atherectomy, so this trial guide us to be [00:04:00] more selective in intervention in carotid artery disease. Well, for me nasa really, it remains a landmark trial because they did follow people out and it was really highlighting the fact that for this specific group of patients who had high grade narrowing over over 70%, that there was a marked difference in the way that we could help these patients avoid stroke. We would not make them smarter. And we always told them that we weren't gonna undo a stroke, that if they had had one, but we would reduce the risk of stroke not to zero, but substantially more. And it took quite a bit of time to convince a lot of our neurologists of the fact that in these cases, you know, specific, and that was a smaller group of patients, not everybody had greater than 70% and were symptomatic that we really. Could help them and that they weren't giving anything up by having them come to surgery and [00:05:00] then go back to them for follow up. Yeah, that's interesting. Dr. Hazer, why do you think you guys had so much difficulty convincing the neurologist? You know, I think there were some neurologists who felt as if they were giving up a patient to a surgeon that they had failed the patient somehow. I don't know exactly the reasoning behind that, but for quite some time I felt that they really believed that Best Medical Management was the way to go for those patients. And it did highlight the fact that giving patients best medical management was a help versus a patient getting nothing, especially those in the 50 to 70% stenosis range who didn't clearly need an operation. One important thing to mention is that best medical management then is not the same as our best medical management now. Yeah. For me, the way I've always viewed an asset is it was done when I was five. I mean, it's a very old trial. It was an excellent trial when it was done, but if you take it at face value. That these [00:06:00] patients are gonna benefit as much as they did in that trial. It's inaccurate because our best medical therapy is much better now. Yeah, fair enough. Yeah, I think that's a great point. The best medical manage has improved a lot, but even in the best trials, the medical management never is a hundred percent accurate for every patient, but at the same time. The surgical management and surgical techniques has improved a lot. That is also true that the surgical techniques have improved, so, yeah. Yeah. All great points that are being brought up and something I considered while reviewing this trial. So do you guys use 70% as a hard cutoff for patients? What do you do when you have a patient, let's say, who had a recent TIA, not a debilitating stroke, relatively healthy, that doesn't quite meet that cutoff, maybe let's say 60, 65% stenosis. You know, we looked at patients from the nasa trial actually [00:07:00] in the 50 to 69% range in terms of cost. And that included the cost, the tremendous cost that one incurs if someone has a stroke. And for males, not females, 'cause the female numbers were smaller, but for males, 50 to 69% symptomatic, actually again. This is historical data with what? What? Now, we wouldn't consider best medical management or even best surgical management, but there was a cost benefit to reducing the number of strokes in those patients too, because there's, there was no question that you had an upfront cost of the patient almost double the cost in 30 days of a stroke risk. Yeah. But yeah, once you got past that, you actually reduced the risk even in the 50 to 69% range. Now, I will say, I think most of us rather. Then operating on those patients are a little bit more aggressive about following them close more closely. So doing studies maybe every three months or every six months and you know, [00:08:00] keeping a lot, lot closer track of those patients. Yeah, I'm with Paul. I wouldn't say that everyone in the group who is symptomatic gets surgery. I would say the women, you're gonna have a much higher threshold. It depends on what type of stroke it was. And the other thing is, let's say you have that symptomatic stenosis, but you're seeing the patient nine or even six months after they had the symptoms and now they're on best medical management. I don't think any of us are considering doing those patients if they're under 70%. So you know, it's an interesting group of people, but I do think if you see that person in the acute period and they're male, you're definitely thinking about doing it because it's hard not to take that patient to the operating room when they've had a symptomatic stroke. And again, even though NASA is almost as old as I am, it is [00:09:00] like our bible for treating these patients. Yeah, that's a lot to consider. Any thoughts on that subgroup, Dr. Flores? Probably in patients who are symptomatic with the best treatment, they have been ongoing and it seem to be a, a failure. So I would be more inclined to intervene in, in that group of patients, provided the rest of the factors or general conditions, so forth. Mm-hmm. To be an excellent risk with good life expectancy and so forth. Yeah. I think that's a great point on the life expectancy thing that we haven't touched on yet, that really affects whether you're gonna do the surgery at all, because these people who have a lower life expectancy are less likely to benefit. But people have to live, I would say, at least five years to really see a benefit. We in general take five years as a general recommendation and. Not only for life expectancy birth, [00:10:00] but also we have to consider all the risk factors such as hypertension, coronary artery disease, history, stroke, COPD, and put everything together. Okay? A lot to take in. So NASA clearly established the role of surgery for symptomatic high grade stenosis, but what about when we add stenting into the mix? That's where our next trial comes in. The carotid revascularization, endarterectomy versus Stenting trial or crest, published in 2010. This directly compared carotid endarterectomy to carotid stenting. Over 2,500 patients, both symptomatic and asymptomatic, were randomized to CEE or stent. The primary endpoint was stroke, mi, or death during the peri-operative period, plus ipsilateral stroke up to four years. The outcomes were relatively similar in the perioperative period. There was a higher incidence of MI with the CEA and a higher incidence of stroke with stenting. Age also [00:11:00] seemed to play a role as stenting had a better result in younger patients, and CEA had better results in older patients over 70 or so. Dr. Hazer, any reason why you think that stenting was more successful in younger patients? I think that most people felt it had a lot to do with the vascular calcifications and the aortic arch. Many of the lead in trials up to Crest looked at circumferential calcification as being a non-starter for stenting because of the risk of stroke when this finding was present. And when it comes to the arch, older patients have a more disease, more calcification, and a higher instance of the type three steep aortic arch, which means that the operator must do a lot more manipulations to get through the common carotid, which adds to the risk. I think that very true, we played. Good attention to the, lemme tell you, throughout the years, many years back, the number of patients on started was a small, very small line. [00:12:00] As time went by, now we see the patient. Most all the patients are started. Very seldom you see the patient with peripheral vascular disease or other vascular issues without a study. The reason I'm saying that is the complication thereof. Embolization, micro embolization following angiography, coronary, the angio angiography is, was most significant in term of blood dose. And that probably has some implication working in the arts and having a stroke and so forth. So, very careful doing extremity work or. Central work and look the patient's statins or no statins and usually if they're not a statin, which is still, I see a small group of patients that are not in the statins, it should be no placed on the statins. So something we have to keep an eye on. Oh, great points. [00:13:00] Dr. Flores, you know, some important things that we should clarify are that when they're saying stenting was more successful in younger patients compared to older patients, successful meant the outcomes that were measured at the time. The other thing is the age thing really didn't matter quite as much when they looked at it for TAR. It's important to remember that in this discussion when we're talking about stenting, we're really talking about transfemoral, not trans carotid. When you bypass the arch, like with TAR, it seems that the issue of younger versus older patients becomes less important. Or maybe it's also the flow reversal that's used with TCAR, Dr. Harrington, for those nonvascular people listening. What does TCAR stand for? Trans artery revascularization, and it's a newer technique that's it's been around for some time, but it's more recent development in vascular surgery. Yeah, I know we're gonna talk about that coming up too. But I think the other thing I can add to is [00:14:00] that, you know, the the stenting group still had a higher rate of stroke than the carotid endarterectomy group. In all ages. And so some of the, the view of looking at Crest and then separating out the 60 to 70 year olds versus the 70 to 80 year olds mm-hmm. Was really post-production, statistical analysis, and not really the way that the the study was intended, which was to look at, you know, stroke, mi, and death. And then they've, they've also broken down. How serious is the mi. And there's been a lot of discussions about that. You know, versus how serious was the stroke? And yeah, there, there are camps of interventional cardiologists and interventional neuro radiologists who will say, well, the, the stroke wasn't so bad. And then there were surgeons who say, well, the, the mi you know, the mi really wasn't that bad. Very few deaths in both groups, which was great. And you know, that's a positive way to look at it. So. [00:15:00] I think for the purposes of our current discussion, the strokes, the issue with the strokes was that they tended to be more debilitating long term. And that's why quote unquote, there's, there's this success element of CEA, and that's true for the asymptomatic patients as well. And for the older people specifically, they have less reserve in theory. So when they get a stroke, it's even worse. For example, if you're saying maybe that stroke wasn't so bad, well, in an older person, you know, having a minor stroke may matter more, and that's why the outcomes, I guess, tended to be worse. Yeah. Another thing we haven't touched on is that there was up to a 5% cranial nerve injury with CEA versus zero in the stenting group. Now very few of those were permanent entries and most of them got better. They also didn't look at hematoma or groin complication rates. A lot of these people had to be anticoagulated for about two weeks or so [00:16:00] beforehand. In the peri interventional period, the incidence of hypotension and bradycardia post-op was not zero, but then again was not recorded. So there are some other subtle things we can delve into, and as Dr. Flore said earlier, you have to look at the whole patient. So all great points, Dr. Hazer. And I think if we're gonna talk about all those, we're probably gonna have a second podcast. Dr. Flores, when did you start doing carotid stents in your practice, and did this trial change anything for you? Well, let me tell you, during my early years open in that ectomy was the only choice as a stent was introduced and proved to be of great value. Now we're confronted with the decision making. Which patient will benefit from stenting, which patient will benefit from surgery. Yeah, exactly. Great point. Dr. Flores, so that makes the decision a little bit harder. So Dr. Harrington and Dr. Hazer, how do you decide between stent versus CEA provided that the patient has an adequate vessel for [00:17:00] both? Well, I'll, I'll answer first and then I'll let Dr. Harrington 'cause he has even a lot more experience in terms of some of the newer interventions. You know, initially some of it was patient preference. We would discuss with some patients. Some patients actually preferred the open surgery. Some didn't like the stenting. There is a recurrent risk for stenosis that is higher with stenting than it is with endarterectomy. There is a little bit more aggressive need for follow up in terms of coming back to see the patients on a more regular basis with the, with the stenting. So some of it had to do with the location of the bifurcation if it was very high. And I thought it was gonna be a very difficult endo ectomy, I'd be more inclined for stenting. But that was one of the advantages of having been part of actually the initial trial and part of my fellowship training was doing some of the first stents to feel comfortable doing both. So I, I felt like a big advantage in terms of that. Now I, I think I'll turn this over to Dr. [00:18:00] Harrington because now with the trans carotid arterial revascularization or T car. I think it's been a game changer in a lot of ways from what, from what I see. And I would just add one caveat that I still am very hesitant or concerned about circumferential calcification or very significant sort of almost polypoid kind of lesions or ulcerations. In terms of putting in a stent, I feel a lot more comfortable getting rid of all that. Radu as we call it. I think we talked about why you might choose one technique over the other, but you know, we're talking about transfemoral, not TAR, which is a whole other bird and is still a stent. I personally mostly do TAR, which is obviously a little bit different. That risk that you see in the older patients is mostly gone, if not completely gone. So for me, the first thing I'm looking at is the anatomy. So if it is a high lesion TCAR [00:19:00] is usually easier to do. You have a long working length, and that allows it to be more easy to deploy the stent. If it's a low lesion, less than five centimeters from the clavicle, that's off-label for TAR. You don't have the. The working room you need. And so in that particular instance, it makes carotid endarterectomy easier. And just to be clear, a very high lesion is also gonna make it more difficult to do a carotid endarterectomy. So that's an easy way. I decide, you know, overall I do prefer TAR because it's a faster procedure. The incision's a little bit smaller and I, I personally feel the healing is a little bit better. For the issue that Dr. Hazer was talking about with the circumferential calcifications. For the last year or so, or even really for the last five years, I've leaned more towards endarterectomy for those cases. But now more people seem to be incorporating intravascular [00:20:00] lithotripsy into their TA procedures. And I think that kind of changes the dynamic because now you can use that to soften up the calcium and then you can put in the stent without some of the limitations that you had before. There are some caveats to that regarding the thickness of the calcium, but overall, I do think it changes the discussion a bit. Overall, I think the, you know, as Dr. Hazer said, the calcification and the arch are the really biggest issues. Interesting. Yeah. TAR is something we're not including too heavily in this talk, but it's definitely a newer weapon in the armamentarium of the vascular surgeon. So just to clarify, Dr. Harrington, if you are decided on a stent, does that mean you're always doing A-T-C-A-R versus a transfemoral? Not always. There are some situations where it makes sense to do transfemoral. Mm-hmm. There are patients who had really heavy radiation to the neck. That maybe makes it less desirable to do that. [00:21:00] Trans carotid cutdown, although they do have a special sheath for that situation. There's also another situation which is interesting and a bit more complex, is when you have a right-sided carotid artery stenosis where if you're technically savvy, you can come from the wrist and do the procedure. So in that case, you really are avoiding the arch, in which case the stroke risk, you know, probably would be similar to TAR. And you're also avoiding an incision in the neck. But yeah, generally because of my training background, I'm almost always doing A-T-C-A-R rather than a more traditional stenting procedure. Yeah. Thanks Dr. Harrington for sharing that. So Crest gave us a head-to-head between surgery and stenting, but what about patients who don't have any symptoms at all but still have severe stenosis? Do they benefit from intervention or is medical therapy enough? F, the asymptomatic carotid surgery trials will help us answer that question. The first [00:22:00] major trial in this space was the a CST one published in 2004 with followup. In 2010, this trial looked at over 3000 patients with asymptomatic stenosis, over 60% randomizing them to immediate car endarterectomy versus deferral with medical therapy. The findings were clear but nuanced perioperative risk was about 3%. And the long-term stroke risk was 6% with surgery persists 11% without surgery at five years for an absolute risk reduction of around 5%. And that benefit persisted at 10 years, but was most pronounced in men and patients under the age of 75. Highlighting that patient selection is also critical, so while a CST one showed that intervention can reduce long-term stroke risk. The upfront procedural risk must be weighed against the potential benefit in certain groups. Fast forward to a CST two published in 2021. This study applies to asymptomatic patients who likely would benefit from intervention, [00:23:00] but were not sure exactly which procedure to offer them. Over 3,600 patients who had over 60% against stenosis were randomized, either receive a CEA, or a stent. Both groups did receive best medical therapy. And that study revealed that both procedures were relatively safe with about a 1% risk of disabling stroke at 30 days. Regarding non disabling stroke at 30 days, stenting had a slightly higher risk at 2.6% versus 1.5% with CEA, and that was statistically significant. At five years. The risk of non disabling stroke was similar in both groups at around 5%. The major limitation of this study was that there was no medical arm, so we can't really draw on the conclusion of whether these patients should be treated surgically at all. But we can perhaps infer that if we put a CST one and two together. So to answer the question for asymptomatic patients, we need to weigh the risk of an asymptomatic patient getting a stroke with the risk of the complications of the procedure. With that, I'll ask the group the question. In your [00:24:00] practice, how do you approach asymptomatic patients and what factors push you towards intervention versus medical management? Yeah, I'm very selective with intervention and patient with asymptomatic disease. I'm inclined to wait until the stenosis reach 80% or greater. At the same time, I start looking for other factors such as type of plaque, presence of ulcerations, evidence of embolization, and together with a good life expectancy and. Low surgical risk were good selected those patients. We tend to benefit from intervention in this asymptomatic growth. I would add to that too, that I think that the progression or lack of progression make a difference for me. Mm-hmm. So if it's 80% and it's been 80%, I will look very carefully at the duplex [00:25:00] scan, at the actual lesions. You know, sort of to, to reinforce what Dr. Flores has said, what type of plaque and the, if the pictures look the same, you know, year to year or mm-hmm. And I tend to be a little bit more aggressive to do at least every six month studies. And that's one of that. The other part is, you know, akin to it, Dr. Flores saying, looking at the patient at their comfort level. You know, a stroke in a patient does not kill them. Most of the time, only about 20% of the time is their fatality. So 80% of patients are gonna have, and some of them may have a severe disability post-stroke. So it mm-hmm. It then depends on the patients as well, because, 'cause I know, you know, what the stroke risk is with surgery or was stenting. And it's, it's certainly well below nowadays, I would say 2%. And it was interesting 'cause I would. Add that while the asymptomatic trials were purely on asymptomatic, [00:26:00] half of the CREST patients were asymptomatic. They did that to boost the enrollment. So you have another asymptomatic group which did better with intervention. When it was over 80, it was actually it in Crest it was over 60%. But still, most of the groups that that participated in Crest would still answer the same, that we we're not gonna intervene unless it's. 80% or more unless there's a lesion that looks very dangerous or worrisome. You guys both gave outstanding answers to that question. The only thing I would add is, as Dr. Flores said before, best medical therapy has improved and so have surgical techniques. That's number one. And then I think just to elaborate more on what Paul was saying about discussions with the patient and the sort of guessing their comfort level and that kind of thing. So when I talk to patients, I literally tell them, I don't know if this is gonna help you. Best medical therapy is [00:27:00] so good, and I usually tell them something along the lines before we do anything. We're trying to prove that we need to do this because it's safer than the risk of not doing it. And I agree with Dr. Flores that nobody is getting this done if it's less than 80%. They have to have a really good expected survival. Their comorbidities need to be well controlled. The ones who are end stage renal are much less likely to get procedure. I have one guy that I did do an endarterectomy on who had CK, D, but the reason we did it was. His stenosis kept progressing. The asymptomatic embolization thing, I would say it affects my decision making if I know about it, meaning they have already had a CT or a diffusion weighted MRI that shows it. But interestingly, although we do do TCDs at our hospital, I don't routinely use that. But maybe it's something that we should be incorporating [00:28:00] more into our practice. I do think in my heart of hearts that most asymptomatic patients just need to be on best medical therapy and be really compliant with it. And best Medical Therapy doesn't just mean high dose statin and aspirin. It means they gotta not smoke. Their diabetes needs to be controlled, their blood pressure needs to be controlled. They have to be eating healthy, exercising. That needs to be clear. That is where Best Medical therapy is. And if they're not on that, they need to have a reasonable trial of best medical therapy before any intervention. Yeah, fair enough. And I think Dr. Haer already touched on this, but it brings up an important point of how you follow asymptomatic patients. I mean, I guess the more severe or worrisome the stenosis, the more you would see them. And is duplex enough or do they need other studies like C-T-E-M-R-E or anything else like that? Okay, I'll continue and yeah, you're, you're right. If it's more severe stenosis, so for example, [00:29:00] greater than 70%, I'm probably doing the duplex every six months. If they have around 50 to 69% I am, I'm doing the duplex yearly. If they're under 50%, but they have significant plaque burden and I'm still surveilling them, then I'll do it yearly. Also, regarding other imaging, if I get a patient referred with over 70%, I'll usually get a CTA to confirm that the duplex isn't underestimating the degree of stenosis. And then if it's still around 70 on the CTA, then I go back to the duplex every six months to see if the velocities are increasing. Or the common carotid to internal carotid artery ratio is changing. I'll even repeat the CTA if the velocities do increase, because, you know, in my experience, not just because the velocity increase means that there will be a significant change in CT finding. S ultrasound is technician dependent. It could be the point where the [00:30:00] tech did their doppler and on the initial duplex, they may have got not gotten the area with the highest velocity. So I always double check with either CTA or MRA. And as you can tell, everyone is super cautious about operating on these asymptomatic patients now because again, best medical therapy has improved so much. Yeah, I think reinforcing that idea. Are you taking your medications? I may spend a little bit more time going into all of the little details of what does it include, best medical management. And that even includes, you know, the Harvard Happiness Studies all over the news about the connections. Having connections with other people and discussions with them and trying to see if they can have their significant other person or persons come in so that you can get a feedback if they really are not having symptoms or. It points out to them, this is super important that you do this. Yeah. You know, we're trying to avoid a stroke and we're trying to do the best thing, so, and then pro probably for me [00:31:00] too as well, every six months. Yeah, I agree. Now six months seem to be very practical. I see the patient repeated so at the fact medication and sometimes I make sure that they're in high dose statins and some of the patients don't realize importance of the medication and they're ready. Oh, I stopped two months. I run out medication. Don't realize. Importance, especially treating critical stenosis at the level of tic, how important it maintain all the medications in place six months interval, adequate for follow up and reinforcing the medical management. Yeah. Thank you all for sharing those insights. I think we've established that the decision to intervene depends heavily on both symptoms and the degree of stenosis, but also on patient factors that don't always show up in the trial data. That brings me to another important piece of the puzzle diagnosis. Before we even get to the point of talking about [00:32:00] surgery or stenting, we first need to know how accurate is the test we're using. Traditionally, carotid duplex ultrasound has been the first line tool, but we also have CTA and MRA available. And of course, historically, catheter-based angiography was considered the gold standard. So I wanna ask all of you, in your day-to-day practice, how much do you rely on duplex ultrasound alone? Do you find CTE or MRA necessary to confirm severity before intervening or help with surgical planning? And is there still any role for diagnostic angiography today? Well question. You know, I love ultrasound, but I never rely on ultrasound alone. I always get confirmatory studies, either CTA or MRA. I'll tell you now, most of these studies that we're discussing did not rely solely on ultrasound. For me, you're using a different technique that may or may not really be consistent with what they were looking at in those studies. So you can't use just ultrasound. I always confirm it with [00:33:00] an additional study. Ultrasound is really good for high grade lesions, but CTA and MRA are are slightly more specific. I tend to do CT scans, but MRI is preferred under some circumstances, which are beyond the scope of this conversation. I think in general, carotid sonogram and CTA by and large for vast majority of patients. But let me set aside, there was a time many years ago. There were many reports of doing otin ectomy based off only on some of them, but that report never changed the practice in general. I think most of us nowadays will do at least two studies, and when you ask about whether angiography still plays a role, I'd say it's very low, but it can be a tiebreaker. Sometimes the CTA will overread because of calcifications and duplex might miss that imaging window. MRA, we used to say, if you're looking for a tight stenosis, MRA, especially [00:34:00] with gadolinium, can be very helpful to pinpoint this, but sometimes there's patient limitations in the ability to get that done or to use gadolinium. If I'm using an angiogram these days, it's with the anticipation that I'm very likely going to be placing a stent either via TAR or in most cases while I'm doing the angiogram, I'd be doing a transfemoral intervention at the same time. But there's still about a 1.2% risk of stroke with angiography. So you have to let the patients know this, and we're looking at one to 2% risk of stroke with intervention. So I want them to know we're doing this because we have a high suspicion that they have a high grade lesion. And I'm especially reserving this for patients who are symptomatic, the asymptomatic patients. I might check an MRA in addition to a CTA and a duplex skin. Yeah. Okay. Wow, that was a lot of information. There's lots of data out there on carotid disease and the decision making process can be quite nuanced. To help us put together all the information we [00:35:00] discussed, I'm gonna present a few scenarios that we can answer together. So first case, a 65-year-old man with a recent TIE found to have 80% stenosis of the left ICA on duplex otherwise healthy. Well, he is young, so let's do a transfemoral stent. I mean, in reality the correct answer is carotid endarterectomy, but you could say stenting is another option. There were some consensus guidelines that said carotid endarterectomy is better overall, but either option would be acceptable, I think some type of intervention to reduce the stenosis and risk of further symptoms. What do you think Dr. Flores? Endarterectomy will be my number one choice. For me, the patient's probably getting a TAR, I'll be honest. Yeah, that's good. Okay. Next case. 72-year-old woman, 40% asymptomatic stenosis of the right ICA found incidentally on ultrasound during a cardiac workup. She's on an aspirin, she's [00:36:00] on a statin. Blood pressure is well controlled. I think this is a fairly easy one. Yeah, no brainer. Okay, so let's take it a step further then. We're not gonna intervene on this patient, but you see this patient in the office. When would you repeat that duplex? 40% stenosis? I do it in a year. Yeah, one year. For me too, if the report come from the outside, I will always repeat the duplex in the office to validate the findings. Yeah, fair enough. And for this patient, you wouldn't get a CTA or anything like that, would you? No, but I have had a patient in the last six months where the duplex under read the degree of stenosis. So your question isn't you know, like totally out of line. Yeah. I think Dr. Harrington and Flores make good points. Yeah, great points from everyone. Okay, let's move on to scenario number three. 78-year-old man who is symptomatic with a 75% stenosis. On CTA, his internal carotid artery is heavily calcified and tortuous. Otherwise he's healthy. So definitely a [00:37:00] TAR patient. This one? No, I'm joking. Yeah, probably endarterectomy. Maybe you want to do an e-version if it's very tortuous and you can reduce the redundancy if you're savvy with that. I don't really do e-version, but I know Paul does. Yeah, sometimes. You know, so minus the tortuosity and depending on where the stenosis is, so let's say that it's tortuous beyond the stenosis and the bifurcation itself isn't actually torturous as long as you have a landing zone for the stent. I would even in this patient consider doing intravascular, litho, phy and the stent, depending on the way his anatomy is. There are some cal calcifications that even with csor you can cut the calcium. And I have a couple of those cases. Yeah, I would say too, you know, for the aversion and ectomies. Especially when they're heavily calcified Once you've cut through it and you, you do sometimes have to really struggle. Some of those are suit the aversion is actually almost all the time, very [00:38:00] easy. And so even if you think they're gonna need a, a, a shunt you can avert that you know, pop that out in, in 20 seconds or so and then put the shunt up. And so, I, I tend to, in those cases, especially if I wanna shorten the carotid to get rid of the kink. That's going on there. I think that that's helpful to have. Yeah. Nice. That's a, that's a cool technique. Tozer next one, 68-year-old woman, 80% stenosis on screening duplex, and she has well controlled hypertension and diabetes. No priors, TIA, strokes, asymptomatic, otherwise functional. And remember, 80% stenosis. Keep an eye on her. I would get a CTA to confirm it's actually 80%. Yeah. As Dr. Flores alluded to earlier, this is the type of patient I may wanna get a diffusion weighted MRI of the brain to see if there are symptomatic lesions that might be showering on the same side. Yeah, that's a great point. TCD also, as we mentioned before, another useful study that might be [00:39:00] incorporated. Yeah. TCD as well. Yeah. Okay, last one. 60-year-old male, recent, TIE. 55% stenosis of the right. ICA. He's a smoker, but otherwise healthy. How recent? Let's say six months. Six months. I'm not doing anything. Let's say 30 days. That makes it a little bit more truly symptomatic. I think I would still probably do best medical management 'cause he's. Not on best of medical management. In reality, he's smoking. Right. I, I'd agree and I would read him a riot act about quitting smoking and then I might see him the following month for sure, within three months time to make sure he's actually quit smoking and he is on best medical management if he needs either a nicotine patch, hypnosis the, the one 800 number for quitting. And I would also, I think get a CTA. Yeah, I think the most important. Factor is make sure that the patient quit smoking. [00:40:00] And I agree with the CTA or MRA, but smoking is a critical issue and unfortunately, patient don't realize the damage is done with the smoking. Alright. Wow, that was a lot to get through and a lot of great discussion and talking points. Hopefully now everyone realizes how nuanced the decision making with carotid surgery can be. And look into the future. We may even need to do another podcast where we go into some more depth on T card, Dr. Ton's favorite or CREST two trial, which may give us more answers or perhaps even leave us more confused. Yeah. Okay, everyone. That brings us to the end of our session today discussing carotid revascularization. To sum it up, NASA showed that surgery clearly helps patients with symptomatic high grade stenosis. A CST extended that to asymptomatic patients showing a smaller but real long-term stroke reduction if the perioperative risk is low. And CREST showed that stenting and endarterectomy have similar long-term outcomes, but with different [00:41:00] periprocedural risks. Hopefully next time you get that consult carotid stenosis. This talk will make it easier to frame your thought process and decision making from all of us here at Behind The Knife, dominate, dominate the day.