Time for a Case Discussion

Recent CHF? Ischemic or from diastolic dysfxn? What's his echo/cath/nuclear stress? Given his risk factors, this guy sounds ripe for a MAC / carotid stent since his odds of post-CEA MI probably outweigh the risk reduction of future stroke. If his anatomy isn't conducive to a stent (or the plaque is unstable) we're doing an awake CEA with a plexus block. I hope pre-op valium and a whiff of methadone has been started and continued for DTs / withdrawal sxs. Duoneb preop. Versed, fentanyl prn, a-line, second IV, 5 lead, insulin, precedex, phenylephrine, and cardene gtts. Titrate SBP to 170-180, keep 140-160 after clamp off or shunt is taken out. Pray he doesn't start tombstoning until he's out of the PACU.

I would also be OK with "hey, you're 80, you've had a good run considering how badly you've abused your body. optimal medical management. laterz"

"
Below is a summary of the results of randomized controlled trials; the 3 earlier studies are omitted because they were performed early in the development of CAS and do not reflect current technique.

Naylor et al, in a prospective, randomized trial of CEA versus CAS for symptomatic patients with greater than 70% internal carotid artery stenosis, found that all 10 of the CEA patients proceeded without any complications, whereas 5 of the 7 CAS patients had an ischemic stroke within 30 days of the procedure.[5] The trial was stopped because of the dramatically bad outcome in the endovascular group.

Brooks et al, in a randomized study of 104 patients presenting with cerebrovascular ischemia related to internal carotid artery stenosis who underwent either CEA (51 patients) or carotid artery stenting (53 patients), reported 1 death in the CEA group and 1 transient ischemic attack in the CAS group.[6] CAS was equivalent to CEA and does not carry an increased risk of major complications (ie, death or stroke). Authors recently published 10-year outcomes for 173 patients. Half of the patients had died from other conditions in this period. They did not find any difference in long-term protection against ipsilateral stroke in either group. Overall, the risk of heart attack was high among patients randomized to CEA.[7]

In the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS), a multicenter clinical trial in which 504 patients with carotid stenosis were randomly assigned to undergo either CEA (253 patients) or CAS (251 patients), there was no substantial difference in the rate of ipsilateral stroke over a 3-year follow-up period.[8] However, the results of surgery were worse as compared to surgical standards for CEA; moreover, cerebral protection devices (CPDs) were used in only 27% of the patients who underwent CAS.

The Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial, an industry-sponsored randomized, controlled trial that included 334 high-risk surgical patients who underwent either CAS or CEA, concluded that CAS was superior to CEA among high-risk surgical patients.[9] The primary end points were combined death, stroke, and myocardial infarction (MI). An asymptomatic rise in troponin levels was regarded as MI, and the higher rate of MI among patients who underwent CEA shifted the balance in favor of CAS.

In the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), which included 2502 patients who were randomly assigned to undergo either CEA or CAS, the combined risk of death, MI, or stroke (the primary end points) was comparable for the 2 procedures (6.8% for CEA vs 7.2% for CAS).[10] However, the incidence of stroke was 2.3% for CEA versus 4.1% for CAS. The incidence of MI was 2.3% for CEA versus 1.1% for CAS. Stroke is a disabling event, and extreme caution should be observed in interpreting the results from CREST.

A recently published subanalysis of the CREST trial[11] showed that restenosis and occlusion rates were similar up to 2 years after CEA and CS."

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Time for a Case Discussion