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Carotid artery revascularisation

Session presentations
  • The asymptomatic patient. Presented by J Rother (Hamburg, DE) See the slides
  • Results of randomised trials and registries. Presented by M Roffi (Geneva 14, CH) See the slides
  • How to optimise surgical results. Presented by M Grabenwoeger (Vienna, AT) See the slides
  • How to optimise endovascular results. Presented by A Cremonesi (Cotignola, IT) See the slides
Peripheral Arterial Diseases


Overall the session provided everything-you-need-to-know-about carotid revascularisation for all cardiologists, with a well-balanced and updated overview of all therapeutic aspects of carotid stenosis.

The session started with a lecture of Pr. Joachim Röther (Hamburg, DE) on asymptomatic carotid stenosis, a condition found up to 12% in men > 70 yrs.  While the risk of stroke is increased in these patients, this risk appears dramatically reduced in the most recent studies, highlighting the beneficial effects of an active optimal medical therapy, especially the use of antithrombotic drugs and statins. Additionally, 45% of ipsilateral strokes to a >50% carotid stenosis are related to other causes (lacunar or cardioembolic). All these data, along with the recent ESC guidelines, are in favor of a prudent approach when considering revascularisation in case of asymptomatic carotid stenosis, given the minor benefits in most cases. Data from ongoing trials (SPACE-2, ACST-2) are eagerly awaited to clarify the contemporary management of these lesions.

An update of the results of randomised trials and registries has been presented by Pr. Marco Roffi (Geneva, Switzerland). Recent meta-analyses showed an increased risk of death and stroke in patients who underwent carotid stenting (CAS) compared to those treated by carotid endarterectomy (CEA). Conversely, MI rates were significantly higher in the CEA vs. CAS group. Even minimal, the post-operative MIs are associated with increased mortality during mid-term follow-up, in contrast to post-operative minor strokes. However, several older trials included in these meta-analyses required limited level of experience. More contemporary registries have shown a temporal trend to decreasing rates of death and stroke. More recent studies show comparable rates of death/stroke after CAS as compared to CEA. The CAS technique is now mature.

Pr. Martin Granbenwöger (Vienna, AU) reviewed factors associated with an improved outcome after CEA. Patients should not only be evaluated according to the stenosis degree but also plaque morphology. In case of stroke, the role of carotid stenosis should be rapidly identified and a prompt intervention within the 2 weeks is mandated. Carotid shunt in case of contralateral occlusion is suitable. Intra-operative control of the brain oxygenation using NIRS and angiographic control is associated with better results, along with an appropriate post-operative monitoring and optimal control of blood pressure in intensive care units.

Similarly, several aspects may improve the patients prognosis after CAS, as thoroughly reviewed by Pr. Alberto Cremonesi (Catignola, IT). The technique would be optimal with pre-procedural evaluation of the common carotid anatomy, stent selection and the use of embolic protection devices. The two latter are rapidly evolving with improved results with the latest devices.

References


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SessionTitle:

Carotid artery revascularisation

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.