I think we're going to get started with our last session. This is Point-Counterpoint Discussion of Asymptomatic Carotid Disease. So we're going to first present you the microsurgical anoderectomy route followed by endovascular balloon-assisted stenting and then no treatment surgically and just medical management. So it is an honor to have Dr. Anil Nandep, again, our honored Donahue lecturer, present the open component followed by Dr. Adnan Siddiqui who's going to present the endovascular component and Dr. Gabrielle Vidal who will present the medical management. Thank you. So my disclosures, I don't do carotid endoterectomies. I was doing, I want to be real honest about it. I used to do them. I love doing them, but, you know, I was doing less than five a year and I said morally I can't be doing this. So my junior partner does them, but he's got like 10 a year. So I was like maybe I should be doing them. Let me see. So I named this, I just want to tell you I'm going to be going to Rutgers so I'll be leaving Louisiana. It's always good to look into the history of carotid. This is one of the great, the Willis Lecture on the Evolution of Surgery Prevention of Stroke. And it's one of the, for those of you that have history buffs, I would strongly recommend this paper. It's a beautiful piece, really researched it. Until I read this paper, I didn't know the word carotid comes from the word caros, to sleep. And if you look at the history, if somebody pressed on your carotid and if you look at the Greek Parthenon, I did this for you, Star. You can see the meteo there, the centaurs pressing on the warrior's neck because they knew that's how they'll make him pass out. So the word caros comes from there. So I thought that was interesting. And let me go this way. And then, of course, the history of strokes. Hippocrates talked about apoplexy. And Ambrose Pari decided, Ambrose Pari also called this the caros vessels. He said if you press on the carotid, you will fall asleep. Yeah. I think for us, I remember the resident, that the thing, the sort of the pivotal change that came in carotid artery disease was when NASCIT came out. NASCIT came out and then everybody realized this is the thing to do. It was cost effective. It worked. But I think the one thing that we, as much as we espouse for surgery, I think that 3% number is key. If your periprocedural morbidity is 8%, you're not helping anybody. And I think 3% is extremely important. So I call this the tale of three cities, because there's three ways to handle this, you know? If you're in the Islamic faith, you go to Mecca. If you're Catholic, you go to Jerusalem or the Vatican. If you're Hindu, you go to Varanasi. And I think Charles Dickens, when he tells about the tale of two cities, says this is the best of times. And I think the three real modes of treatment for the disease are conservative medical management, stenting, or endarterectomy. And here we are to sort of debate each of these options. This is the ECAST study that showed about 2,500 patients that showed benefit for this, about 60%. And then if you look at long-term results. And these trials really showed it was an equipoise between stenting and an endarterectomy. But this was the guidelines that came out from the Italian group. And you can see that it says that if there's no myocardial infarction history, you know, there's a risk of myocardial stub, that this is, unless you're doing it at a specialized stenting center, and I'm sure Adnan will tell you that he works at a highly specialized center, which probably has a much lower rate. But unless you're doing it, in fact, the Italian guidelines was that a shift from carotid endarterectomy as the surgical treatment choice is currently not recommended. And this is 2018 that this just came out. So unless you're part of a trial, and I think their defense in Europe is if you're not doing high volume and you don't have a center. I mean, that kind of perplexed me because I think in Europe, especially in France, clipping is a dead art out there. They don't clip, everything is coiled. And I would have thought that with carotids, it would be the same. This is long-term results against stenting versus endarterectomy. And it showed equipoise there. I think I'm going the wrong way again. And this is a great meta-analysis. They looked at 233,000 patients, 51 studies. And the risk of carotid endarterectomy decreased over time and did not change significantly over time. I think the big caveat with carotid endarterectomies is myocardial history. There's a higher rate of myocardial infarction. And the one thing that I could not be able to decipher, because some people tend to do the carotid endarterectomies under local. And I'm curious if the risk of MI in that subgroup is better. Adnan is nodding his head no. But I thought that would be something interesting to look at, yeah. I'm going the wrong way again. So this just shows you long-term follow-up 2005. You look at the long-term follow-up. The risk is in both symptomatic and is down. And then you look at the stroke and death rate. It did not change significantly over time. So the data is clear-cut. I think those that are skeptical of this, unless you're older, unless you have major medical issues, I think it's not something that we are equivocal about. This is a meta-analysis that came out, pooled incidence of all strokes. And this paper felt that carotid endarterectomy is the preferred option for treatment of asymptomatic carotid stenosis. I think I have a Chinese study. This is a Chinese study that, again, was a meta-analysis. And they looked at 3,000 patients. They concluded the meta-analysis. And, again, it was the same answer, yeah. Keep going the wrong way. So this is another review article. I wish I had mine. And, again, so I think, you know, unless there's contraindication, I think you've had previous radiation, you've had a tracheostomy, laryngeal cancer, there stenting comes in. And I'm curious how the rest of the group feels, especially with medical management and stuff. I'm going the wrong way again. And this is just a meta-analysis. It shows the superiority. I think the key thing also is that perhaps we're not diagnosing the disease enough. This is a great study from Norway that showed that the number of endarterectomies or treatment of carotid disease was really underrepresented. So it's almost like the appendix thing, that if you have a 90 percent, if you have a 100 percent appendectomy rate, you're missing some appendices. And I think that's true for carotid. I've always felt that we're not treating this enough, especially in the south where I've lived for a long time. And the southern stroke rate was much higher, but we would find workups are not complete, not done, so it's something to think about. So I would end it with the ecclesiastic, what has been is what will be. There's nothing new under the sun. And I think there was such resistance to endarterectomy. When I started my training, we would, before NASCA came out, just tells you how dated I am on this issue, before NASCA came out, there was such a brouhaha that endarterectomy was the most unnecessary surgical procedure. The New York Times would have full page, you know, full articles on this, that this is completely unnecessary, it's not indicated. And it was like gallbladder surgery where we're doing too much of it. And I think NASCA proved you needed it, and I think now we've moved the pendulum to asymptomatic. I think you're more than 60 percent. You will benefit. But I think Arthur Clark put it best, new ideas pass through three periods. It can be done. It probably can be done, but it's not worth doing. I knew it was a good idea all along. So I think that would be a great way to segue for Adnan saying it's a great idea all along. Thanks. Thank you.

microsurgical anoderectomy route

asymptomatic carotid disease

endovascular balloon-assisted stenting

medical management

carotid endarterectomy