Carotid Therapy: Controversial Management of CAS

Session explores management of CAS with results from CREST-2 trials.

By Brenda Silva

As ISET 2018 continues, an important morning session focused on results from the CREST-2 trials in relation to managing carotid artery stenosis (CAS). Moderator William Gray, MD, introduced the topic to a panel of experts who provided insights gained from the CREST-2 trial and offered updates on the growing area of interventional stroke therapy.

First speaker Barry Katzen, MD, offered an update on the CREST-2 Trials and what the trial is expected to do for CAS therapy options. “This is really a trial comparing medical management, and one of the benefits of the patients that enter this trial is that there is a strong patient support system in place for them.”

He continued, “The CREST-2 trials are not a final answer, but provide a lot of answers to help all of us in finding the best treatment at any time for patients with asymptomatic carotid disease.”

Up next, William Gray, MD, explored new technologies for carotid stenting and pointed out that when it comes to minor strokes/microembolization, new options involve a carotid post-dilation balloon with integrated embolic protection. He also reported another consideration for minor direct carotid access is a device with a high-rate flow reversal.

Claudio Schonholz, MD, took the podium next to discuss embolic protection during CAS, with regard to filters, occlusion, and flow reversals. “Filters only catch large particles, they will not catch small particles. On the other hand, flow reversal has the ability to catch the small particles, but they have their own issues as well. What we need to remember is that all embolic protection options for CAS have both pros and cons; it’s a matter of choosing the one that’s right for your individual patient.”

Kenneth Rosenfield, MD, spoke next about what we can learn from the CREST-2 registry. “The primary objective of the trial was to rapidly initiate and credential operators of the registry. Because CAS reimbursement is limited to symptomatic, high surgical risk patients, we’re seeing a decrease in the use of overall carotid revascularization stenting.”

Summing up, Dr. Rosenfield said, “The challenge addressed was to allow carotid stenting to be performed and allow for additional enrollments in the trial. There is great variation in experience and technique that still exists, which can provide a platform to disseminate education and standardize a platform. One of the goals of the CREST registry is the hope that it will lead to new monitoring and an enhancement of clinical care.”

The next speaker was D. Chris Metzger, MD, who looked at best techniques in 2018 for CAS performance at low risk.

“How do we perform low-risk CAS? Good case selection in personal training. Scrub in to watch as many CAS cases with good operators, and avoid difficult cases in your first 100 cases. Over time, carotid stenting keeps getting better, and proximal embolic protection may improve results even more. We need to focus on careful patient and lesion selection, avoid bad anatomy for every patient, and perform an individual CAS risk assessment for each patient.”

He added, “CAS is an excellent procedure when performed by experienced operators, but it is not a replacement for the value of stenting.”

Following next, Michael Jaff, DO, explored if there was any reason for debate with regard to intervention for carotid artery stenosis. He said, “We don’t need to have a debate because there is no reason for one. So why didn’t CREST end the debate? Reimbursement challenges; the largest population we see is asymptomatic, standard-risk patients, which affects how challenges can be addressed.”

The final speaker, Italo Linfante, MD, offered an update on the status of stroke intervention. “The future is bright for stroke patients because of early treatments and emerging new products and technologies. The most important aspect of stroke intervention is the window of time for intervention, and that window is now 24 hours or more.”