Data and discussion forefront carotid session at ‘pivotal moment’

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Pallavi Manvar-Singh

Contemporary management of carotid disease after the Centers for Medicare and Medicaid Services (CMS) carotid artery stenting (CAS) decision memo and prior to CREST-2 results will be the focus of an Education Session at VAM 2024.

In October, CMS released its final decision regarding NCD 20.7 covering CAS. The move was made to expand Medicare coverage for CAS to include patients who have symptomatic carotid stenosis of 50% or greater and asymptomatic carotid stenosis of 70% or greater.

The timing of the decision has been a point of contention, having been made prior to the 2026 expected release date of CREST-2 results. This trial will compare intensive medical management alone to intensive medical management plus revascularization with carotid endarterectomy (CEA) or transfemoral CAS (TF-CAS) in patients with high-grade stenosis.

The VAM 2024 session, set for the afternoon of Friday, June 21, at 1:30 p.m. (West Building, Level 1), will see Pallavi Manvar-Singh, MD, of the Zucker School of Medicine at Hofstra/Northwell Health in Jericho, New York, and Peter Schneider, MD, of the University of California San Francisco in San Francisco, California, moderate eight podium presentations and extensive discussion.

“The management of carotid bifurcation occlusive disease is a core competency for vascular surgeons and vascular surgery continues to be vital to the development of optimized therapy for this disease process,” Manvar-Singh and Schneider told VS@VAM ahead of the Chicago meeting.

They continued: “Vascular surgeons are experts in the disease process, the longitudinal management of these patients, and different methods of carotid repair when it is indicated, whether by CEA or stent.”

The pair further remarked that therapy for both symptomatic and asymptomatic carotid disease “is well studied but remains quite dynamic” and that “updates on important developments will help us predict how the field is evolving.”

“It is a pivotal moment in the evolution of carotid disease management,” they commented. “Any one of these developing issues could substantially shape our future practices. The recent NCD is an endorsement of stent-based therapy by CMS.

“The pressure to reduce treatment and avoid screening for critical asymptomatic stenosis is increasing. The CREST-2 trial is nearly enrolled. TCAR [transcarotid artery revascularization] is nearing 100,000 procedures in the U.S., and most vascular practices have incorporated it as an option for repair.

“The growth of stroke centers will undoubtedly influence our practices, but we don’t yet know how. For all these reasons, an update on carotid disease management is essential to inform our treatment plans.”

Opening the session, Caitlin Hicks, MD, of Johns Hopkins University in Baltimore, Maryland, will deliver a review of the NCD, before Warren J. Gasper, MD, of the University of California San Francisco, shares an update on the CREST-2 trial.

Mark F. Conrad, MD, MS, of Steward Health in Brighton, Massachusetts, is due to speak on asymptomatic disease, after whom Sonya S. Noor, MD, of Gates Vascular Institute in Amherst, New York, will address the question, “Should vascular surgeons be involved in stroke centers?”

After some discussion time, the focus will turn to data. Sean P. Lyden, MD, o the Cleveland Clinic in Cleveland, Ohio, will present new data covering TF-CAS and new technologies since the last NCD, and Gregg S. Landis, MD, of the Zucker School of Medicine at Hofstra/Northwell will outline the totality of data available supporting TCAR.

The final two presentations of the session before another round of discussion will cover technique and training, respectively, from Mazin I. Foteh, MD, of Cardiothoracic and Vascular Surgeons in Dallas, Texas, and Jeffrey Jim, MD, of Minneapolis Heart Institute at Abbott Northwestern Hospital in Minneapolis, Minnesota.

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