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Fundacin Favaloro Carotid Artery Stenting in Asymptomatics Oscar A. Mendiz. MD.FACC.FSCAI Chief Interventional Cardiology SOLACI President August 2012

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Fundacin Favaloro Conflictos de Interes Nombre: Oscar A. Mendiz Medtronic: Proctor para CoreValve. Elli Lilly; Speacker AstraZeneca: Advisory Board Sponsors para viajes a Congresos: Acher (Cook), Angiocor (AGA), Cordis, BSCI, Cordis, Medikar, Sanofi. 2

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Fundacin Favaloro Carotid Stenosis Asymptomatic: ~75% Symptomatic: ~25% Normal Risk High Risk ~10%~25%~15%~50% Modified from M Jaff, 2007 Carotid Artery Disease

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Fundacin Favaloro Historical use only? NASCET Trial: events at 5 years in asymptomatic patients Barnett HJM, et al. JAMA. 2000;283:1429-1436 Note: 1-45% of the neuro events were NOT related to the carotid lesion 2-Similar events in >60 and >70% stenosis Although some data suggests you cannot use >80% as lone criteria in asymptomatic pts, it is somehow arbitrary Only 15% were receiving lipid lowering agents!!!!

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Fundacin Favaloro Medical Treatment Improvements ACE- Inhibitors vs. Placebo Cardiovascular Endpoints 0.5 1.0 2.0 Stroke166/6060 240/6064 CAD539/6060672/6064 CHF 154/6060 183/6064 CV death 307/6060 416/6064 Total death533/6060632/6064 0.70 (0.57-0.85) 0.80 (0.72-0.89) 0.84 (0.68-1.04) 0.74 (0.64-0.85) 0.84 (0.76-0.94) Number of Events/ Total Patients ACE-I Placebo Relative Risk (95% CI) Blood Pressure Lowering Treatment Trialists Collaboration Lancet, 2000; 355: 1955-64; HOPE, PART2; QUIET, SCAT

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Fundacin Favaloro Medical Treatment Improvements Statins: Stroke Reduction in High Risk Ptes Mark C Bates. www.tctmd.com

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Fundacin Favaloro Received Mxm after 2003 272 pts Medical Treatment Improvements: Statins Carotid Intima Media Thickness reduction with Atorvastatin Improvements on TCD Outcomes Mark C Bates. www.tctmd.com 471 Patients with ACS Received Mx before 2003 199 pts HITS on TCD 3.7% HITS on TCD 12.6% Conclusion: With more intensive Mx, regression of carotid plaque occurs in half our patients; this has resulted in a marked decline of TCD microemboli and clinical events among patients with ACS. J. David Spence,et al.. More Intensive Medical Therapy has Reduced Microemboli and Cardiovascular Eventsin Patients with Asymptomatic Carotid Stenosis Abstract presented AHA San Diego 2009 Taylor AJ et al. Circulation 2002; 106: 2055-2060 Conclusion: Marked LDL reduction (

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Fundacin Favaloro Annual TIA & Stroke rate reduction in asymptomatic control arms of randomized trials

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Fundacin Favaloro Ann L. Abbott. Stroke. published on-line Aug 20,2009 Caveats: 1. Different patient population (low risk) 2. Improved outcomes with medical therapy have been under the microscope of a clinical trial driven strict follow-up. Patients are selected based on their willingness to comply with these strict guidelines and investigators are admonished for failing to monitor compliance Mark C Bates. www.tctmd.com

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Fundacin Favaloro Improvements on CAS Outcomes over the time Cremonesi Alberto. Linc 2012

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Fundacin Favaloro Improvements on CAS Outcomes over the time: Post Market registries Improvements on CAS Outcomes over the time: Post Market registries Stroke & Death Patients (n = 6,320) Incidence95% CI All Symptomatic Asymptomatic 3.6% 6.4% 3.2% 3.2-4.1 4.8-8.4 2.8,-3.7

Fundacin Favaloro High-Risk Asymptomatic Carotid Stenosis: Ulceration on 3-D Ultrasound vs. Transcranial Doppler Microemboli High-Risk Asymptomatic Carotid Stenosis: Ulceration on 3-D Ultrasound vs. Transcranial Doppler Microemboli Prospective analysis of 253 ACS ptes with >60% carotid stenosis 3-Year Outcomes (incidence) > 3 Ulcers (4%) < 3 UlcersMicroemboli (3%) NO Microemboli Stroke (%)18.21.720.01.7 Stroke or Death (%)18.22.113.31.7 Conclusion: The presence of ulcers or microemboli identify Ptes with Asymptomatic carotid stenosis who will benefit from revascularization rather than optimal medical therapy alone. Madani A, et al. Neurology 2011;77:744-750

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Fundacin Favaloro Silent Cerebral Events in Asymptomatic Carotid Stenosis Jayasooriya G, et al. J Vasc Surg. 2011 Jul;54(1):227-36 Aim: to examine the evidence for subclinical microembolization and silent brain infarction in the prediction of stroke in asymptomatic carotid stenosis using transcranial Doppler (TCD), computed tomography (CT), and magnetic resonance imaging (MRI). A specific pattern of silent CT infarctions was related to future stroke risk (odds ratio [OR] = 4.6; confidence interval [CI] = 3.0-7.2; P