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The Take Home: ISET
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The 27th annual International Symposium on Endovascular Therapy was held in Hollywood, Florida, from Jan. 31 to Feb. 4. Among the attendees at the 5-day conference were L. Nelson Hopkins, MD, State University of New York Distinguished Professor at University at Buffalo and founder of Gates Vascular Institute and Jacobs Institute, and Michael R. Jaff, DO, FSCAI, medical director of the Fireman Vascular Center and Paul and Phyllis Fireman Endowed Chair in Vascular Medicine at Massachusetts General Hospital, who shared their thoughts on the highlights from the meeting.
L. NELSON HOPKINS, MD
Insight on Stroke Intervention
The sessions from Stroke Intervention: From Basic to Advanced were important because recently we had a number of studies that proved that in patients with major stroke, endovascular intervention after administration of IV tissue plasminogen activator (tPA) is better than IV tPA alone. IV tPA has been the standard of care for a long time based on an NIH study conducted many years ago. As recently as a year ago, there were three studies published in The New England Journal of Medicine that suggested that endovascular intervention in patients with stroke was no more effective than IV tPA. The reason those studies concluded that is because they were conducted over a long period of time as the technology evolved, and it wasn’t until the very end of those studies that the newer clot retrieval technology was introduced. Fewer than 5% of patients in all of those trials got what we would consider anything like modern clot-retrieval therapy for their strokes, so it’s no wonder that those studies came out negative for intervention.
But if you actually look at the subset of patients who underwent stroke intervention with a modern device, most of those patients did well. So, the review of those studies at the International Symposium on Endovascular Therapy (ISET) meeting was important in terms of getting us to an understanding that we need to mount an attack on stroke with stroke intervention. That analysis was critically important and the whole session was helpful.
Photo: Solaris Photography; printed with permission.
Carotid Stenting Safety
The sessions on Carotid and Brachiocephalic Interventions and Advances in Carotid Stenting were interesting from my perspective because they focused on how incredibly important it is to minimize any errors in carotid stenting in order to achieve the results that we need to achieve, and to have it accepted by the CMS as a reimbursable procedure for patients with carotid stenosis. In every major study that has been done, including the CREST trial, the problem with carotid stenting is that there was a higher incidence of stroke with carotid stenting than with carotid endarterectomy. The difference was relatively small, and the driver was minor strokes; major strokes were the same in both arms, but minor strokes were more common in the stenting arm. That has been perhaps the biggest obstacle to getting carotid stenting accepted.
L. Nelson Hopkins
The ROADSTER trial, presented in the fall of 2014 at the Vascular Interventional Advances (VIVA) meeting, looked at the new technology of direct carotid stenting, and it showed an incredibly low stroke rate. When operators used the direct approach of the carotid artery in the neck with a small cut-down in the proximal part of the common carotid and then stented from that cut-down, the stroke rate was 0.7%, which is the best reported so far. What was important about that study was that it showed that if you approach carotid stenting by not putting catheters through the aortic arch into torturous arteries, you reduce the risk for stroke significantly. It is an important advance.
Minimizing mistakes and avoiding minor strokes in carotid stenting has to be the goal in order to get CMS to approve payment for this procedure. At ISET, there were several presentations emphasizing how we are going to get to that goal of reducing the risks associated with carotid stenting. This is important because when you look at the population with carotid stenosis, you find that there are some good candidates for carotid endarterectomy, but others who are extremely poor candidates for surgery, and some for whom it is clear that stenting is the better procedure. Right now, for the majority of patients, we don’t have any choice because CMS will not reimburse for carotid stenting except in a small subset of patients who are symptomatic and at high risk for surgery. A major takeaway from this meeting was that we need to overcome that barrier because there are patients who are just plain better for carotid stenting.
MICHAEL R. JAFF, DO, FSCAI
Innovative Approaches
The theme from ISET 2015 was innovation. A lot of time was spent discussing how to innovate in the fields of vascular medicine and intervention. The opening session was about innovation, and other sessions had discussions of the next approaches to complex vascular disease.
The Future of Renal Denervation
The session Renal Denervation: Is It Still in Your Future? was fantastic. The reason is that a lot of people think this is old news in a dead field, but the truth of the matter is that there is a lot of interesting work that has gone on since the SYMPLICITY HTN-3 data on the Symplicity renal denervation system (Medtronic) came out. In addition to analyses about that data, there have been a lot of insights about patient population and trial design, which are thought-provoking. At the meeting, Boston Scientific announced it is even beginning a trial, which will be called REDUCE-HTN REINFORCE.
Michael R. Jaff
Felix Mahfoud, MD, of Saarland University Hospital, Homburg, Germany, gave a great talk about his perspective on these developments and the opportunities that exist. That was one of many outstanding presentations, and there was a good panel discussion about the challenges and opportunities going forward. Having listened to and participated in that panel, it is my perspective that renal denervation is not dead. We were probably too exuberant early on than what was deserved, and now we are probably too pessimistic. I expect the pendulum to swing into the center someplace; things will certainly be better than they looked after the SYMPLICITY HTN-3 data were released.
Live Physical Exam
In the session on Diagnosis and Management of Arterial Disease, I did a live physical examination on a patient in front of the audience. This is the only meeting where I’ve ever done this, and also the first where I’ve ever seen it done. This year, there were about 300 people in the audience. I was examining a person who had known peripheral artery disease. It was a great opportunity to demonstrate certain physical exam findings that a lot of people either hadn’t seen frequently or had never seen before. It highlighted the fact that there is so much you can learn from doing a physical exam that may keep you from even having to do a CT scan or other testing. I think people enjoyed it, and I certainly enjoyed doing it.