Evolution in Management and Treatment of Carotid Artery Disease

 

“There is a ‘one size fits all’ strategy by a lot of people who simply read a paper or a guideline and say that’s how patients must be treated,” said co-moderator Dr. Ross Naylor, professor of vascular surgery at the University of Leicester and a consultant vascular surgeon at the Leicester Royal Infirmary. “This session will question how you actually treat your patients, so I think it will open people’s eyes toward the benefits of modern medical therapy. It also questions the role of carotid stenting in asymptomatic patients and how to reduce the risks; unless we reduce the risks, it’s going to be less likely to be adopted.”

The session has several themes, he explained. One is the benefit of optimizing best medical therapy: “There are a couple of papers on the role of starting statins before carotid surgery or carotid stenting. There’s now good evidence that if you do this, you will reduce the perioperative risk of stroke, and this needs to be emphasized more in guidelines.”

In addition, Dr. Naylor said, there is increasing evidence that patients who have asymptomatic carotid stenosis, and who are started on good quality medical therapy, have much lower annual risks of stroke than they would 15 to 20 years ago. Presentations by Dr. J. David Spence of Western University and University Hospital in London, Canada, and by Dr. Henrik Sillesen of the University of Copenhagen and Rigshospitalet, will question current attitudes toward intervening in asymptomatic patients. “Their big plea is that the majority can be treated medically,” Dr. Naylor said. “Only a small proportion actually will benefit from stenting and surgery.” Dr. Spence will address the value of Mediterranean and Nordic diets in patients with carotid stenosis, while Dr. Sillesen will examine if stenosis or plaque progression are reasons to treat asymptomatic patients with carotid artery stenting (CAS) versus carotid artery endarterectomy (CEA).

Another theme is looking at efforts to reduce perioperative stroke rates after carotid stenting, Dr. Naylor said: “One of the repeated findings is that the death and stroke rates are lower following carotid surgery rather than carotid stenting. Registries suggest that in a large number of series, stroke rates actually exceed the accepted risks for treating patients with asymptomatic disease, which is 3%, or for symptomatic disease, which is 6%.”

Dr. William A. Gray of Jefferson Medical College and Main Line Health will discuss technical strategies that might be used to reduce perioperative stroke rates, including new techniques and devices such as the double-filter Paladin device. Dr. L. Nelson Hopkins, SUNY Distinguished Professor of Neurosurgery and Radiology, University at Buffalo, will discuss how strokes after CAS and other interventional procedures have greater cognitive deficits than previously thought, even with full neurological recovery.

The discussions will conclude with a presentation by Dr. Mark H. Wholey of the University of Pittsburgh Medical Center, Shady Side, on the etiology, diagnosis and treatment of vertebral artery dissections. “It is so vanishingly rare that we are asked to treat this that almost nobody has any experience,” Dr. Naylor said. “I suspect this will be quite an interesting talk for the audience.”

Co-moderators for the session will be Dr. James May, Emeritus Bosch Professor of Surgery and associated dean of surgical sciences at the University of Sydney, and a vascular surgeon at Royal Prince Alfred Hospital; Dr. Wesley S. Moore, professor and chief emeritus of vascular surgery at UCLA Medical Center; and Dr. Enrico Ascher, chief of vascular surgery at NYU Hospitals, and professor of surgery at New York University.

 

“There is a ‘one size fits all’ strategy by a lot of people who simply read a paper or a guideline and say that’s how patients must be treated,” said co-moderator Dr. Ross Naylor, professor of vascular surgery at the University of Leicester and a consultant vascular surgeon at the Leicester Royal Infirmary. “This session will question how you actually treat your patients, so I think it will open people’s eyes toward the benefits of modern medical therapy. It also questions the role of carotid stenting in asymptomatic patients and how to reduce the risks; unless we reduce the risks, it’s going to be less likely to be adopted.”

The session has several themes, he explained. One is the benefit of optimizing best medical therapy: “There are a couple of papers on the role of starting statins before carotid surgery or carotid stenting. There’s now good evidence that if you do this, you will reduce the perioperative risk of stroke, and this needs to be emphasized more in guidelines.”

In addition, Dr. Naylor said, there is increasing evidence that patients who have asymptomatic carotid stenosis, and who are started on good quality medical therapy, have much lower annual risks of stroke than they would 15 to 20 years ago. Presentations by Dr. J. David Spence of Western University and University Hospital in London, Canada, and by Dr. Henrik Sillesen of the University of Copenhagen and Rigshospitalet, will question current attitudes toward intervening in asymptomatic patients. “Their big plea is that the majority can be treated medically,” Dr. Naylor said. “Only a small proportion actually will benefit from stenting and surgery.” Dr. Spence will address the value of Mediterranean and Nordic diets in patients with carotid stenosis, while Dr. Sillesen will examine if stenosis or plaque progression are reasons to treat asymptomatic patients with carotid artery stenting (CAS) versus carotid artery endarterectomy (CEA).

Another theme is looking at efforts to reduce perioperative stroke rates after carotid stenting, Dr. Naylor said: “One of the repeated findings is that the death and stroke rates are lower following carotid surgery rather than carotid stenting. Registries suggest that in a large number of series, stroke rates actually exceed the accepted risks for treating patients with asymptomatic disease, which is 3%, or for symptomatic disease, which is 6%.”

Dr. William A. Gray of Jefferson Medical College and Main Line Health will discuss technical strategies that might be used to reduce perioperative stroke rates, including new techniques and devices such as the double-filter Paladin device. Dr. L. Nelson Hopkins, SUNY Distinguished Professor of Neurosurgery and Radiology, University at Buffalo, will discuss how strokes after CAS and other interventional procedures have greater cognitive deficits than previously thought, even with full neurological recovery.

The discussions will conclude with a presentation by Dr. Mark H. Wholey of the University of Pittsburgh Medical Center, Shady Side, on the etiology, diagnosis and treatment of vertebral artery dissections. “It is so vanishingly rare that we are asked to treat this that almost nobody has any experience,” Dr. Naylor said. “I suspect this will be quite an interesting talk for the audience.”

Co-moderators for the session will be Dr. James May, Emeritus Bosch Professor of Surgery and associated dean of surgical sciences at the University of Sydney, and a vascular surgeon at Royal Prince Alfred Hospital; Dr. Wesley S. Moore, professor and chief emeritus of vascular surgery at UCLA Medical Center; and Dr. Enrico Ascher, chief of vascular surgery at NYU Hospitals, and professor of surgery at New York University.

 

“There is a ‘one size fits all’ strategy by a lot of people who simply read a paper or a guideline and say that’s how patients must be treated,” said co-moderator Dr. Ross Naylor, professor of vascular surgery at the University of Leicester and a consultant vascular surgeon at the Leicester Royal Infirmary. “This session will question how you actually treat your patients, so I think it will open people’s eyes toward the benefits of modern medical therapy. It also questions the role of carotid stenting in asymptomatic patients and how to reduce the risks; unless we reduce the risks, it’s going to be less likely to be adopted.”

The session has several themes, he explained. One is the benefit of optimizing best medical therapy: “There are a couple of papers on the role of starting statins before carotid surgery or carotid stenting. There’s now good evidence that if you do this, you will reduce the perioperative risk of stroke, and this needs to be emphasized more in guidelines.”

In addition, Dr. Naylor said, there is increasing evidence that patients who have asymptomatic carotid stenosis, and who are started on good quality medical therapy, have much lower annual risks of stroke than they would 15 to 20 years ago. Presentations by Dr. J. David Spence of Western University and University Hospital in London, Canada, and by Dr. Henrik Sillesen of the University of Copenhagen and Rigshospitalet, will question current attitudes toward intervening in asymptomatic patients. “Their big plea is that the majority can be treated medically,” Dr. Naylor said. “Only a small proportion actually will benefit from stenting and surgery.” Dr. Spence will address the value of Mediterranean and Nordic diets in patients with carotid stenosis, while Dr. Sillesen will examine if stenosis or plaque progression are reasons to treat asymptomatic patients with carotid artery stenting (CAS) versus carotid artery endarterectomy (CEA).

Another theme is looking at efforts to reduce perioperative stroke rates after carotid stenting, Dr. Naylor said: “One of the repeated findings is that the death and stroke rates are lower following carotid surgery rather than carotid stenting. Registries suggest that in a large number of series, stroke rates actually exceed the accepted risks for treating patients with asymptomatic disease, which is 3%, or for symptomatic disease, which is 6%.”

Dr. William A. Gray of Jefferson Medical College and Main Line Health will discuss technical strategies that might be used to reduce perioperative stroke rates, including new techniques and devices such as the double-filter Paladin device. Dr. L. Nelson Hopkins, SUNY Distinguished Professor of Neurosurgery and Radiology, University at Buffalo, will discuss how strokes after CAS and other interventional procedures have greater cognitive deficits than previously thought, even with full neurological recovery.

The discussions will conclude with a presentation by Dr. Mark H. Wholey of the University of Pittsburgh Medical Center, Shady Side, on the etiology, diagnosis and treatment of vertebral artery dissections. “It is so vanishingly rare that we are asked to treat this that almost nobody has any experience,” Dr. Naylor said. “I suspect this will be quite an interesting talk for the audience.”

Co-moderators for the session will be Dr. James May, Emeritus Bosch Professor of Surgery and associated dean of surgical sciences at the University of Sydney, and a vascular surgeon at Royal Prince Alfred Hospital; Dr. Wesley S. Moore, professor and chief emeritus of vascular surgery at UCLA Medical Center; and Dr. Enrico Ascher, chief of vascular surgery at NYU Hospitals, and professor of surgery at New York University.