We talked amongst us, and I took some liberties here because I knew Mahmoud would talk at length about the various data sets that he's been a part of, and Mahmoud, thank you for being at this meeting and contributing so mightily. It's been brilliant. I think we've all been enriched by it, so thank you. And I saw that talk yesterday, so I thought I would leverage that talk to something a little bit different in terms of how we make decisions within carotid stenting, or with carotid management. You've already heard a little bit about, more than a little bit, you've heard a lot about various subsets of patients in the carotid, Abstract Carotid Classification Disease set that may or may not do better with certain types of therapies. And what I'm going to try to do is summarize, without any papers, but summarize the data that Mahmoud just described. And he said in his last comment that we really need a randomized trial, but absent a randomized trial, the best thing we have is some of the data he has discussed, and some of the expert opinion on this panel and elsewhere, from experiential outcomes. So I'm going to kind of go down that path. So Gary kind of touched on this. In the era of transition from surgery to endovascular, which has really been going on for the last 25 years, and not just in carotid disease, but in coronary disease, and vascular disease, and elsewhere, and aneurysm disease, carotid stenting, I believe, was kind of the unfortunate poster child. It was one of the earlier ones, and probably the most controversial of the bunch. It was less invasive, potentially had the potential to reduce scarring, bleeding, infection, trauma, and anesthesia, a quicker return to function, and better patient experience. The problem was it was really brought to the field by an alternative group of practitioners who weren't really managing carotid disease at the time that Gary and Jay and others envisioned this. And it was a new set of technologies and skills not familiar to the surgeons who were managing carotid disease at the time. And so the adoption was dictated by the comfort and skill set required for the non-surgical procedure, and quite honestly, the traditional carotid endodirectomist was not prepared for an endovascular approach to that same territory, regardless of what we think the outcomes would be. And it's more than understandable that this would be a perceived existential threat to existing operators. And unfortunately, there was a devolution of specialty relations and, I believe, a worsening of patient care as a result of these intramural squabbles. Too often, rather than talking about the disease state, we talked about the procedure that I own. So if I'm a carotid center, I own that, and therefore, that's all I can offer, and the same thing with endodirectomy or TCAR. And that doesn't really serve the patient well, as you'll see in a moment. And this is really driven as a specialty phenomenon where we're guarding against our own skill set deficits. I can't do an operation. And we're doing the practice procedure protectionism as well. Our strengths are accentuated in both our conversations, our referrals, as well as our publications. And our weaknesses are minimized. And again, this doesn't serve anybody, because it doesn't get to the nut of the science, which is really what we care about. And the end of it all, now that we have 25, 30 years of experience with stenting, close to 70 years of experience with endodirectomy, and about 10 years of TCAR experience, it's pretty obvious, I think, to people in the field that there's no single approach to most patient conditions anywhere, not just in carotid disease. So in the end, patients are not well-served without consideration of all the options and a complete menu of them. So I'm going to go through the options and just kind of do an abridged version of what Mahbub Mujahid did and talk a little bit about what the various options bring to the table and then kind of combine them in a Venn diagram you'll see in a moment. So if we differentiate features among the therapeutic options in medical management, we have to take into account life expectancy. If somebody's not going to live a long time, medical management may be the best therapy for them because it takes three to five years for most carotid surgeries or stents to play out as a benefit to amortize the risk of the procedure over the course of the benefit of the long-term stroke reduction. Rate of lesion progression. If the lesion's been stable for five, ten years, there's no real reason to intervene on it. But if it progresses quickly in the last, you know, six to 12 months, that is a reason to move. Have you heard about age? This will be important as it relates to life expectancy, but also if you have a 55-year-old sitting in front of you, it's different than if you have an 85-year-old in front of you in terms of what therapy you might choose, and medical management may be elevated there. And when I say medical management, I mean medical management without intervention. Everybody's going to get medical management. Compliance with medica- the ability of a patient to comply with medical therapy, smoking cessation, metabolic management. A lot of patients can't do that, to be very honest with you, and they have progressive atherosclerotic disease in spite of themselves. Plaque morphology. We don't talk about this a lot. There's a whole science around plaque morphology, microembolic hits that are silent, silent DWI abnormalities. Unfortunately, they're high specificity but low yield- sorry, low sensitivity, because we don't see a lot of them in every patient. But when we see them, it may be very helpful to consider them as a consideration to move to a more aggressive management. And then there are the various inherent risks, anatomic and comorbid, that make medical management maybe more attractive than other things. For endarterectomy, and again, you heard this, and I'm summarizing this without the literature, but if there are minimal anatomic or comorbid risk factors, lesion location, not too high, active coronary disease, heart failure, aggressive heart failure, class, resonatic lesions, radiation of stoma, those kinds of things, then you would kind of potentially move away from that. Endarterectomy. A recently symptomatic patient, I think, is probably best served by endarterectomy today, but there's- we could argue about that. Age over 75, it's- as the data has been described, it's true that stenting doesn't do as well as endarterectomy over the age of 75, probably related to arch anatomy and tortuosity in the common carotid vessels, but more importantly, recognize that age over 75, if you operate on an 85-year-old and do endarterectomy, that risk is still higher than if you operate on a 55-year-old. And we don't talk about that enough because we say, oh, over 75, his risk is much better with endarterectomy. No, it's not. It's actually higher with endarterectomy than it would be in a younger patient. So we have to acknowledge that as well. Life expectancy we talked about, and then, very important, surgical experience and local outcomes, critically important. Differentiating features for carotid stenting, favorable lesion anatomy. We don't tackle difficult lesions because we don't do well with them. Long lesions. You heard about this before. Long lesion, calcified lesion, tortuous lesions, and so on. Endarterectomy risks should be present and can be helpful in determining or kind of flipping the needle away from endarterectomy and towards stenting. Not recently symptomatic. Now, there are plenty of patients who I've done who are symptomatic, but I would submit that if they have a reasonable surgical risk, that their first best choice, and we might want to have a discussion about this, might be endarterectomy. No access issues, either femoral, aortic, or common carotid, and age less than 75, with caveats mentioned before. For TCAR, it's very similar. The issue there is more about common carotid artery length and disease-free state, and we already talked about all these other things, which we won't repeat. So now, I'm going to summarize these things in what I think is kind of a decision diagram, which I think is an interesting beginning of how we can start thinking about this now that we have access over the last six months to all of these technologies. So in the middle, and you can tell me the number, 80, 70, 90, I don't know what the number is, but the vast majority of patients can be treated with any of these therapies and do incredibly well. We've shown, at least in comparative data between endarterectomy and stenting, that they are equivalent in tens of thousands of patients. Now, for TCAR, we don't have comparative data, but we do have prospective carefully-gathered data, and it looks similar, but there is a bit of a deficit there in terms of comparative data. For all of these, low surgical risk, good femoral radial common carotid access, young patients, recently symptomatic, favorable lesion anatomy, patients are going to do pretty well with just about everything. So I'm going to put them right in the middle of the circle for the Venn diagram. But there's these other quadrants or other slices of the Venn diagram which might be useful to talk about. So what about patients who might do better with endarterectomy? Well, low surgical risk, complex access vessel anatomy, short or diseased common carotid arteries, which can't be done through TCAR, recently symptomatic, and unfavorable lesion anatomies, long lesions, calcified lesions, tortuous lesions, better done with endarterectomy. Equivalent, I would say, between stenting and endarterectomy are the low surgical risk patient, good femoral radial access, young, short disease, common carotid, not accessible by TCAR, and favorable lesion anatomy. Carotid stenting, a high surgical risk, either anatomic or comorbid, but they don't have to be. They can be normal surgical risk, good access, young patient, and favorable lesion anatomy. Stenting and TCAR are interesting. I like to say that TCAR and stenting, by any other name, it smells as sweet. And the bottom line is that many of the same features that are favorable for stenting are favorable for TCAR except for access. So we don't really have to worry about aortic arch and femoral access for TCAR. They just have to have a good common carotid artery. The rest of them are very similar. And then for TCAR alone, we've already talked about that, difficult transfemoral access and favorable lesion anatomy. And then lastly, TCAR and endarterectomy, actually pretty reasonable alternatives if there's difficult access, recently symptomatic, or favorable lesion anatomy. So you can see that, you know, if you're the guy with the hammer, everything looks like a nail, but you have to realize that there's multiple tools in the set. And my last slide is really around how we manage the different tools. Outcomes in all of these therapies are evolving to the positive, and that's great for our patients. This covers, expands, and now allows us to consider all three options, four options with medical therapy. And the best data we have suggests that the judicious, expert, and selective use of all of these therapies in a complementary fashion can really improve overall outcomes. That is, if you do high-risk endarterectomy, you're going to get a bad outcome more times than not. You don't need to do that. You can lower your endarterectomy risk profile as a surgeon if you complementarily use stenting or TCAR in those high-risk patients. So you can actually make yourself look better by dishing those patients to the right operator. Interoperator referrals will be necessary in those circumstances. I don't do surgery. I don't do TCAR. And therefore, I need to be willing and able and know who I should be referring to in my community. And if we do this effectively, it should make all procedures safer, fewer strokes, less MIs, less disability for our patients and their families, remember, and less cardiovascular mortality in our patients and families will benefit. So that's just kind of a quick sweep of what I think Mahmoud kind of detailed with a lot of data analysis. But I think putting into practice how I counsel my patients. Thank you very much. Thank you.

carotid disease

treatment options

personalized care

specialist collaboration

patient outcomes