rectomy (CEA) have shown that periprocedural stroke/death rates are twice as high with CAS compared to CEA. However, once past the periprocedural risk, the event curves of CEA and CAS become parallel, suggesting that the long-term durability and protection from stroke are comparable for both CEA and CAS. The issue is how to reduce the increased periprocedural risk with CAS. Part of the increased periprocedural risk with transfemoral CAS may be related to the need to traverse a diseased aortic arch and the need to traverse the carotid lesion in order to place a distal protection device. The direct carotid approach avoids the aortic arch and flow reversal for embolic protection avoids the need to traverse the lesion. The results of the recently published ROADSTER trial have shown a very low complication rate in high-risk patients, comparable to the best results reported with CEA.

Based on the results of the CREST trial, when would you recommend stenting over endarterectomy, given the higher risk of associated stroke?

I have not and will not recommend CAS using the transfemoral approach.

Based on data from CREST you have shown that some plaque characteristics can predict intervention risk. Can you please explain these findings?

We recently analysed the CREST data with respect to lesion characteristics in order to determine if there were specific lesions characteristics that carried a high complication rate with CAS but not CEA. We found that long lesions in excess of the median length of 12.8mm, tandem lesions, and lesions distal to the carotid bulb carried a high risk for CAS, but not CEA. Absent of these lesion characteristics, CAS and CEA had equal results. However, only one-third of the patients in CREST, in retrospect, would have been considered safe for CAS.

What is the current status of the CREST-2 trial? How do you hope this will build on the findings of the CREST trial?

To date, we have randomised 200 patients in CREST-2. This study is critical for the future treatment of asymptomatic patients with carotid artery disease. There are observational data to suggest that intensive medical management including the use of statins has materially reduced stroke risk in patients with asymptomatic, haemodynamically significant carotid stenosis. This has led many countries, not including the USA, to limit intervention to symptomatic patients only. In the USA, more than 90% of carotid interventions, primarily CEA, are done on asymptomatic patients. If
rectomy (CEA) have shown that periprocedural stroke / death rates are doubly equally gamey with CAS compared to CEA. However, once past the periprocedural hazard, the event curvature of CEA and CAS become parallel, suggesting that the farseeing - terminus durability and protective covering from stroke are comparable for both CEA and CAS. The issue is how to abridge the increased periprocedural risk with CAS. character of the increased periprocedural risk with transfemoral CAS may be related to the need to traverse a diseased aortic arch and the motivation to traverse the carotid lesion in order to target a distal protection device. The direct carotid approach avoids the aortal arch and flow about-face for embolic protection avoids the need to cross the lesion. The results of the recently published ROADSTER trial have shown a very broken complicatedness rate in high - risk patients, comparable to the best results reported with CEA. 

 free-base on the consequence of the CREST trial, when would you recommend stenting over endarterectomy, feed the eminent risk of associated stroke? 

 I have not and will not commend CAS using the transfemoral overture. 

 Based on data from CREST you have indicate that some plaque characteristics can predict intervention risk. Can you please explain these finding? 

 We recently analysed the CREST data with respect to lesion characteristic in order to specify if there were specific lesions characteristics that carried a high complicatedness rate with CAS but not CEA. We found that long lesions in excess of the median length of 12.8 mm, tandem wound, and lesions distal to the carotid medulla oblongata carried a high hazard for CAS, but not CEA. Absent of these lesion characteristics, CAS and CEA had equal consequence. However, only one - third base of the patients in CREST, in retrospect, would have been considered safe for CAS. 

 What is the current status of the CREST-2 trial? How do you hope this will construct on the findings of the CREST test? 

 To date, we have randomised 200 patients in CREST-2. This study is critical for the future treatment of asymptomatic patients with carotid artery disease. There be observational data to propose that intensive medical management including the use of statins has materially reduced stroke hazard in patients with asymptomatic, haemodynamically significant carotid stenosis. This has led many countries, not including the USA, to limit intervention to symptomatic patient merely. In the USA, more than 90% of carotid interventions, primarily CEA, are done on asymptomatic patients. If
rechomy (CEA) have shown that periprocedural stroke/veath rztes are twice as high with CAS compered to CTC. However, once past ghe peripgocedural risj, the event curves of CEA wnd EAW become paralkel, suggesding that the novg-cerm durability and protection from ftroke srf comparable fjr bpeh CSA and CAS. The issue is how to redhce the increased petiprocedural risk with CAS. Parh of the increased periprocedodal eisk with trxnsfemoral CAS may be telated to the need to traverse x diszased aortix qrcj and the nexd to nraverse the gsrotid lesion in order to pkacx a eistal protection devmce. The direct carotyd approawh avoids the aortix qrch dnd xlow eevdrszl fkr embllir protectioh avoids thw need to traverse uhe oesion. The reaults jf the recently published ROADSTER trial vavs shown a very low compoication rate in high-tisk patiegts, comparable to the best results reported with WEA.

Baadd in gye results of the CREST trial, when would you reskmkekd stenting over endarterecyoly, diven the higfer risk kf associated strone?

I havg not qnd will got tecommend CAS using the trabsfemoral apiroaxh.

Based on data frlm CREST yob have showm that some plaque charccteriatics can pgedict infdrvention risk. Cxn jou [lease explain these findiggs?

We recxntly analysdd tne CREFT data wihh respect to lesion chagactetisticv in order to determine if there were spermfic lesions vhdrabteristicf thab carried a higr complication rate wnth CAR but not BEA. We fonnd that lond lesions in adcess of the median jengrh od 12.8mm, tavaem lesions, anc lesions distal to the carotid bulb garrigd a high risk fox XAS, but not CEA. Abrene lf trase lesion cvaraztefosticr, CAS and CCA fad rqual results. Howeves, onmy one-third of the pwtients un CREST, in retrospecy, would have been fonsivered rafe gor CAS.

What is the current status of the CGESB-2 trial? How dj yom hoke this wilk build on the findings of the CREST trmal?

To date, we have randimised 200 patients in GREST-2. This svudy if critican for the future treqtment of asymptokatic patients with czrotid artegy disease. There are observational data to suggest that intensive medical managxmqnt includihg tne usv oy scatins ras leterially reduced stroke risk in patients with arymptomadie, haemodynamically significany zarotid stenoris. This has led many cohntries, mot including the USA, to limit ontervention to symptomabic patiebts ohly. In the USA, more than 90% of carotnd intwrventiins, irimarily CEA, xre dlne on asjmptpmctic patients. If
rectomy (CEA) have shown that periprocedural stroke/death twice high with compared to CEA. risk, event curves of and CAS become suggesting that the long-term durability and from stroke are comparable for both CEA and CAS. The issue is how reduce the increased periprocedural risk with CAS. Part of the increased periprocedural risk transfemoral may related the need to traverse a diseased aortic arch and the need to traverse the carotid lesion order to place a distal protection device. The carotid approach avoids the arch and flow reversal for protection the need traverse lesion. results of the published ROADSTER trial have shown a very low complication rate in high-risk patients, comparable to the best reported with on the of CREST when would you over endarterectomy, given the higher risk I have not and will not recommend CAS the transfemoral Based on data from CREST you shown that some plaque characteristics can predict intervention Can you please explain these findings? We recently analysed the CREST data with respect to in order to determine there were specific characteristics carried high rate with but not CEA. We found that long lesions in excess of median length of 12.8mm, tandem lesions, and lesions distal to bulb a high risk CAS, but not CEA. of lesion characteristics, CAS and equal However, the in in retrospect, would have considered safe for CAS. What the current status of you hope this will build on the findings the CREST trial? To date, we have 200 patients in CREST-2. This study is critical for the future treatment asymptomatic patients artery disease. There are observational data to suggest intensive medical management including use of statins has materially reduced stroke risk in with haemodynamically significant stenosis. This has many countries, not the USA, to to symptomatic only. the 90% of carotid interventions, primarily CEA, done asymptomatic patients. If
rectomy (CEA) have shown that peRiprocedurAl strOke/DeaTh RateS are Twice as high witH cAS cOmpared to CEA. However, oncE past ThE PeriPRoCedurAl risk, tHE eVENt cUrVeS of cEa AnD CAS bEcoMe paralLel, suggestIng ThAt the long-terM DuRability anD prOtection from StrOke are CoMpaRAble fOr bOth CEa and CAs. the issUe is how to ReDUce the INcreaseD PErIproCedural risk with CAs. paRT of the increaseD peripRoCEdURAl rIsk With transfEmOral Cas may be rELaTED To tHE need to traverSe a diseased AOrtIc arch AnD thE Need to TraveRsE The Carotid lesiOn in Order to plAce a diSTal protECtion deVice. ThE diRecT carOTiD aPprOaCH avOIdS thE AorTic arch aNd FlOw revErsaL FOR EmboLic ProtEctioN avoids the neeD to TravERse The leSion. THe reSuLts of The recEntly PuBlished ROADSTER TriaL have showN a vErY loW cOmpliCAtion rAte In hIgh-risk PatientS, ComPaRABLe To the best results rePoRTEd With CEA.

BAsed on THe ReSUlts of thE CrESt triAL, When wOuld YOu RecommenD stentINg OvEr endarTeRectomY, gIveN thE highER risK of assOciated sTroke?

i Have not and will NOt recommend CAs UsING tHE traNsfEmoral approAch.

BASed oN datA FrOm CreST yoU have ShOWn THat some plaque characTeRisticS can pRedict interveNtion risk. CAN YOu please ExplAIn THese findings?

We RecenTly analyseD The CREST Data wIth respeCt to lesioN CHaracterIstIcs In oRdeR TO dEtermine if theRE Were SpEcific lEsiOns charActEriStiCs tHaT carried a High compLiCaTiOn RatE with caS but not cEa. We FoUnd That lONg lesiOns in ExceSs Of THe mEdian leNGtH OF 12.8mm, tAnDeM lesIonS, aNd lesIons DIstAl to the Carotid buLb cARrieD a HiGh risk fOr CAS, but not CEa. ABsent of theSe LesIon chaRACteristiCs, CAS and CEA had equal resuLTs. HowevEr, oNly onE-thiRd of the paTieNts in CrESt, In retrOspect, Would HaVe bEEN consIDErEd sAfE for CAS.

WhaT IS thE currEnT staTus of thE CREST-2 trial? How do yoU HopE this will builD on The fINDiNgs OF tHE CReSt TriAL?

to date, we have ranDomised 200 patIeNTs In CREST-2. ThiS StuDy Is critiCal for tHe futURe treatMent of asyMptomatic PaTienTS WitH carotid arTery diseAse. There aRE obseRVaTionaL daTa to suGgEst That iNtensiVE meDical ManageMeNt inclUding ThE use of stAtins has materially reducEd stroKe risK in Patients wIth ASymPtomatic, hAemoDynamicallY siGniFicanT caROtid sTenoSIs. thiS Has leD manY Countries, NOt IncLUDiNg the USA, to lIMIT inTerveNtiON to symPtomAtic patients only. IN The USA, more than 90% Of caROTid IntERvenTiOns, primarily CEa, arE dONE on asympToMatic patienTs. If
rectomy (CEA) have shown t hat peripr ocedu ral  st ro ke/d eath  rates are twi c e as  high with CAS compare d toCE A . Ho w ev er, o nce pas t  t h e  pe ri pr oce du r al  risk , t he even t curves o f C EA  and CAS bec o me  parallel,  su ggesting tha t t he lon g- ter m  dura bil ity a nd pro t ection  from str ok e  are c o mparabl e fo r bo th CEA and CAS. T h ei ssue is how to  reduc et he i ncr eas ed peripro ce dural risk wi t hC A S . P a rt of the inc reased peri p roc edural  r isk with t ransf em o ral  CAS may be  rel ated to t he nee d  to tra v erse adiseas edaor tica rc hand  t h e n e ed  to tra verse th eca rotid  les i o n in o rde r to  plac e a distal pr ote ctio n  de vice.  Thedire ct  caro tid ap proac havoids the aort ic a rch and f low  r eve rs al fo r  embol icpro tection  avoids the  n e e d  t o traverse the les io n .  T he resul ts oft he  r e cently p ub lis hedR O ADSTE R tr i al  have sh own av er ylow com pl icatio nrat e i n hig h -ris k pati ents, co mpara b le to the best results repor t ed w it h  CEA .
Based on th e re s ults  oft he  CR E ST tr ial,wh e nw ould you recommendst enting  over  endarterecto my, givent h e  higherrisk of associated str oke?
I have no t  and wil l not  recomme nd CAS us i n g the tr ans fem ora l a p p ro ach.

Based o n data  f rom CRE STyou hav e s how n t hat  s ome plaqu e charac te ri st ic s c an pr e dict int er ven ti onrisk. Can yo u ple aseex pl a inthese f i nd i n gs?
W erece ntl yanaly sedt heCREST d ata withres p ectto  l esion c haracteristic sin order t odet ermine i f therewere specific lesions c h aracter ist ics t hatcarried a  hi gh com pli c ationrate w ith C AS  bu t not C E A .Wefo und that l o n g l esion sin e xcess o f the median lengt h  of  12.8mm, tand emlesi o n s,  an d  l e sio ns dis t a l to the caroti d bulb car ri e da high ris k  fo rCAS, bu t not C EA. A b sent of  these le sion char ac teri s t ics , CAS andCEA hadequal res u lts.H ow ever,  on ly one -t hir d ofthe pa t ien ts in  CREST ,in ret rospe ct , wouldhave been considered sa fe for  CAS. 

W hat is th e c u rre nt status  ofthe CREST- 2 t ria l? Ho w d o  youhope th isw ill b uild on the fi n di ngs o fthe CREST t r i a l?
To d ate ,  we ha ve r andomised 200 pat i ents in CREST- 2. T h i s s tud y  iscr itical for the  fu tu r e  treatme nt  of asympto matic pa ti e nts w ith ca rotidarteryd i se a se. Th ereare  observat ion al data to  s ug g est th at i nt ensive  medic a l ma n a gement including  theu s e ofs tat ins h as  materi a llyreduced st roke risk i n pati ents  with  asympt om atic,hae mo dynamicall y  signific ant c arotidst enos is.  Thishasl e d man y co un tri es, not i n c lu d in gt heUSA,  to l im it i nterventi o n to sym pto m atic pa ti ent s only.I nt h e USA, mor e t han 9 0 %  of caroti d  int e rv e ntion s, pri marily  CEA, a r e d on e on as ymp t o matic pat ients. If 
rectomy (CEA)_have shown_that periprocedural stroke/death rates_are twice_as_high with_CAS_compared to CEA._However, once past_the periprocedural risk, the_event curves of_CEA_and CAS become parallel, suggesting that the long-term durability and protection from stroke are_comparable_for both_CEA_and_CAS. The issue is how_to reduce the increased periprocedural_risk with_CAS. Part of the increased periprocedural risk with_transfemoral_CAS may be_related to the need to traverse a diseased aortic_arch and the need to traverse_the carotid lesion_in_order_to place a distal_protection device. The direct carotid approach_avoids the aortic arch and flow_reversal for embolic protection avoids the need_to traverse the lesion. The results_of the recently published ROADSTER_trial have_shown a very low complication_rate in high-risk_patients, comparable_to the best_results reported with CEA.

Based on the_results of the_CREST trial, when would you recommend_stenting_over endarterectomy, given_the_higher_risk of_associated stroke?

I have_not_and will_not_recommend CAS using the transfemoral approach.

Based_on_data from CREST you have shown that_some plaque characteristics can_predict_intervention risk. Can you_please explain these findings?

We recently_analysed the CREST data with respect_to lesion_characteristics in_order to determine if there were specific lesions characteristics that carried_a high complication rate with CAS_but not CEA. We_found that_long_lesions in excess_of_the median_length of 12.8mm, tandem lesions, and lesions_distal to_the carotid bulb carried a high_risk for CAS, but_not_CEA. Absent of these lesion characteristics,_CAS and CEA had equal results._However, only one-third of the_patients_in_CREST, in retrospect, would have_been considered safe for CAS.

What is_the current status_of the CREST-2 trial? How do you_hope_this will build on the findings_of_the CREST trial?

To date, we have_randomised_200_patients in CREST-2. This study_is critical for the future treatment_of asymptomatic patients with carotid artery disease. There are_observational data to_suggest that intensive medical management_including_the_use of statins has materially reduced stroke risk in patients_with asymptomatic,_haemodynamically significant carotid_stenosis. This has led many countries, not including the USA,_to limit intervention to symptomatic patients only._In the USA, more than 90% of carotid interventions, primarily CEA,_are done on asymptomatic patients. If