I would like to help doctors and patients facing the problem of symptomatic carotid artery stenosis.

1. The debate about carotid revasc
in symptomatic patients
GA Pelouze MD MSc
St John’s hospital Perpignan France

3. What is the problem?
• NASCET, in 1991 brought the evidence that
carotid endarterectomy is beneficial in some
symptomatic patients
• The Benefit/Risk ratio of carotid revasc is
depending on
– The absolute risk of stroke for the individual
patient
– The absolute risk of stroke or MI or death in the
facility where the revasc is performed

4. How to solve it?
• Doctors needs the best evaluation tools
• Absolute risk of stroke for the individual patient:
http://www.stroke.ox.ac.uk/
• Absolute risk of stroke or MI or death in the
facility where the revasc is performed:
– is it available on the web site of your hospital?
– If yes compute it
– If no try to evaluate it by the morbi-mortality rate of
the team or the operator you chose or put it at 3%

5. What trends are affecting the risks
computed and BTW the decision?
Risk of stroke
• The BMT has largely improved
and there is still a potential
especially about APA efficacy
and treatment of hypertension
• Risk of stroke of other origins
is now better evaluated and
treated especially in case of
comorbidities
• Some situations are still
difficult as treatment of
carotid artery stenosis in the
aftermath of thrombolysis
Risk of revasc
• Stroke is less and less frequent
after CE I mean less than 1% in
experienced hands
• Stroke is less and less frequent in
CAS and new approaches and
semi covered stents are coming
with a potential to reach the rate
of emboli we observed in CE
• Revasc is of maximal benefit
when performed early
• As CREST has shown MI even
minor should be adressed by
complete diagnosis and revasc
pre or postoperatively.

6. What is the Best Medical Decision about
carotid revasc in symptomatic patients?
Improving BMT ASAP
• Stop smoking
• Antiplatelet must be efficient,
heparin could be useful
• Statins should achieve the goal
of LDL cholesterol < 1g/l
• Hypertension should be
treated with proof of efficacy
on 24hours monitoring
• Comorbidities should be
adressed
Improving revasc
• It is not a junior surgery
• When the MMR is not
available it should be
computed at 3%
• When decided revasc should
be done quickly (<1week and
probably <48h)
• CAS should be carefully
monitored as it is a recent
procedure
• Coronary events should be
adressed ASAP

7. About healthcare policies
• Symptomatic patients are the most prone to
benefit of carotid revasc
• Resources should be directed priorily to these
patients because revasc for asymptomatic
patients is far more questionable
• Funding of trials to reevaluate the results of
NASCET and ECST is key 25 years after

8. References
• http://www.nejm.org/doi/full/10.1056/NEJM199
108153250701
• http://www.nejm.org/doi/full/10.1056/NEJMc13
12990?q
• http://informahealthcare.com/doi/abs/10.1586/
14779072.2014.893826?journalCode=erk
uery=TOC
• Ferrero E, Ferri M, Viazzo A, et al. A retrospective
study on early carotid endarterectomy within 48
hours after transient ischemic attack and stroke in
evolution. Ann Vasc Surg 2014;28:227-38