acute treatment of carotid artery disease experience of
TRANSCRIPT
Acute treatment of carotid artery disease Experience of Modena Hospital
R. Moratto Vascular Surgeon
02
R. Moratto
Acute carotid treatment A story from the past
“Flying off Into the brain”
Mrs A, a housewife, aged 66, was in bed Dec. 26, 1953, recovering from a cold when she had her first attack.
She noticed that she could not use either her right arm or leg and that a film had
come over her left eye. About half an hour later she found that she could move her hand and soon afterwards the
sight started to come back in her eye and she could speak. The next attack came on at 2 a.m. the following
morning and was identical with the first.
Up to the time of her operation she had, in all, 33 major attacks .
Eight of these attacks occurred after her admission to hospital on April 9, 1954.
The carotid artery was punctured and three injections of contrast was made………..and was shown an
atheromatous lesion almost occluding the origin of the vessel.
26 Dec.1953 9 April 1954
R. Moratto
Acute carotid treatment How the story end
On May 19 the patient was anaesthetised by Dr C.A.Cheatle and her body temperature reduced to 28 C.
by external cooling. The left common internal and external carotid arteries were exposed and found to be
adherent to the neighbouring structures in the region of the carotid bifurcation. This was freed, the external
carotid artery was ligated and the diseased segment of artery (3 cm long) was resected
Originally it was intended to insert a blood-vessel graft, but this proved to be unnecessary, a direct end-
to-end anastomosis between the common and internal carotid arteries being performed. The carotid artery
was clamped for twentyeight minutes and good pulsation observed in the vessels after removal of the clamp
Anticoagulants were not used.
She was walking fortyeight hours after her operation and left hospital on June 2.
Seen on Oct. 20 she had been doing her household work from a month after leaving hospital
19 May 20 October 2 June
R. Moratto
Transforming an ischemic
infarct into hemorrhagic one
INFARC
T
Edema from
revascularization of
suffering areas
OEDEM
A
Mobilizing emboli from
thrombus or plaque
EMBOLI
Acute Carotid treatment Pessimistic attitude towards an early approach
R. Moratto
IMAGIN
G SELECTION
Acute Carotid treatment Causes of failure
TIMING
R. Moratto
Acute Carotid treatment Importance of timing
The time is the key of treatment
R. Moratto
The early days after an onset are at major risk for
recurrent symptoms. TIA and minor stroke have to
consider as an
Impending
Stroke
Acute Carotid treatment Time & risk of stroke
days 30 60 90
10
20
%
Rothwell PM , Lancet Neurol 2006
R. Moratto
80% is
Acute Carotid treatment Time & risk of recurrence
stroke recurrence
reduction of an early vs
deferred treatment
days 30 60 90
5
10
%
Rothwell PM., Lancet 2007
R. Moratto
Acute Carotid treatment Timing for intervention
Carotid intervention for recently symptomatic severe carotid stenosis should be
regarded as an emergency procedure in patients who are neurologically stable,
and should ideally be performed within 48 hours of a TIA or minor stroke
48 hours
11 Jan.2012 www.dh.gov.uk/publications
R. Moratto
PLAQU
E BRAIN
Acute Carotid treatment Importance of imaging
ARCH
R. Moratto
Acute Carotid treatment Importance of imaging of the arch
The Arch as origin of difficulties
and emboli
access is responsable from 20-30% of
CAS complication and failure
R. Moratto
Acute Carotid treatment Importance of imaging of the plaque
The Unstable or Vulnerable
Plaque
A plaque , often not stenotic , that had a
likelihood of becoming disrupted
and forming a thrombogenic focus after
exposure to an acute risk factor
R. Moratto
Acute Carotid treatment Importance of cerebral imaging
To know state of target organ is
mandatory
time should not be lost in puzzling over
subtle early ischemic signs. Perfusion CT
can delineate the salvageable brain
tissue and CT angiography helps detect
vessel occlusion and collateral flow
R. Moratto
Acute Carotid treatment Importance of correct selection
No selection of Patients was
carried out
We showed that perioperative risk is not increased when CEA is performed within 14 days of a qualifying
neurological event but is significantly higher when surgery is performed within the first 2 days. On the basis
of these results, we suggest that procedural risks of very urgent CEA should be cautiously monitored.
R. Moratto
Carotid stenosis > 60 %
Vulnerable plaque 50%
Carotid occlusion post CEA
Carotid occlusion post CAS
TIA & Crescendo TIA
No lesion at neuroimaging
Same TIA indication and…….
NIHSS < 7
Ischemic core < 2,5 – 3 cm
Minor stroke Major stroke
Lesion at neuroimaging
Acute Carotid treatment Our attitude to patient selection
R. Moratto
Duplex & neurogical exam
CEA
CT scan & CT-
Angiography
Sten
osi
s N
o S
ten
osi
s
Acute Carotid treatment Our current TIA protocol
CT scan & Neurological
Division
CAS
An
ato
mic
al r
isk
R. Moratto
Duplex &
neurogical exam
CT scan/CT perfusion /
CT-Angiography or DWI
Ste
no
sis
N
o S
ten
osis
Acute Carotid treatment Our current STROKE protocol
CT scan - Fibrinolysis ?
Assessment case by case
Tre
atm
en
t
NIHSS < 7
Lesion < 2.5 – 3
No coma
R. Moratto
Acute Carotid treatment What is changed: the recent past
Always general anesthesia
Always shunt
Always angiography
CEA
R. Moratto
Acute Carotid treatment What is changed: the present
Consciuos anesthesia
Selective shunt or in pts not able to collaborate
Intra-operative duplex scan ( angiography only in case of doubt)
CEA
R. Moratto
S. R., male
73 years, crescendo
TIA’s
Acute Carotid treatment Case1: CEA
R. Moratto
Acute Carotid treatment What is changed: CAS
Reduce procedural time
Reduce clamping time
Reduce ischemic time
Possibility to treat tandem lesions
Gold standard tool
CAS
Theoretically advantages
R. Moratto
Acute Carotid treatment CAS preliminary experiences
The results suggest that emergency carotid artery
stenting can improve 7-day neurological outcome …..
Our protocol of treatment of urgent symptomatic
carotid stenosis select, with good affidability , pts who
benefit by intervention …..
R. Moratto
Acute Carotid treatment CAS must mimic surgery
High risk patients, elderly,
with tortuos vessels and
problematic accesses
Unstable plaque with
vulnerability features
To Avoid Emboli
Flushing
Clamping
R. Moratto
Acute Carotid treatment CAS: endovascular clamping
No flow No emboli
R. Moratto
Acute Carotid treatment CAS: endovascular flushing
A flush down of debris towards ECA
R. Moratto
Acute Carotid treatment CAS: stents
Wide gap relates to plaque prolapse
OPEN CELLS CLOSED CELLS or HYBRID
Better than open cells ones , but not
mandatory with flushing
R. Moratto
P. G. , male
62 yr, minor
stroke
Acute Carotid treatment Case2: CAS
R. Moratto
M.L., female
75 years, minor
stroke
Acute Carotid treatment Case 3: CAS
R. Moratto
SIMPLIFIED ACCESS
(Piton)
ANATOMICAL
SELECTION (CT) EPD (MOMA)
PROLAPSE
PROTECTON
(flushing)
EXPERT TEAM
(2 experts)
Acute Carotid treatment CAS: 5 rules
R. Moratto
Young patients
Favorable bifurcation
Difficult accesses for CAS
Contra-indication to double antiplatelet therapy
Elderly patients with favorable anatomy
High bifurcation
Long lesion
Tandem lesions
Hostile neck
CAS
Acute Carotid treatment CEA vs CAS : decision making
CEA
Vs
R. Moratto
Acute Carotid treatment Results
In conclusion, our study demonstrated that early treatment
with CEA or protected carotid stenting is both feasible and safe in
selected patients with first episode or recurrent TIA or minor stroke
CAS and CEA Are both
safe
R. Moratto
Acute Carotid treatment Results
CEA With technical modifications
Is safe
Conclusion: Urgent CAS in selected patients with symptomatic carotid stenosis was
satisfactory in preventing the recurrence of TIA and stroke In this study urgent CAS
with careful patient selection and expert technique may represent a possible solution
for some patients with recent or recurrent TIA or minor stroke.
R. Moratto
Acute Carotid treatment Our experience : Results
Demographic data & symptoms CAS ( 123 pts) CEA ( 150 pts) Total ( 273 pts)
Males 95 114 219
Females 28 36 51
Average age 77
( min. 50 – max. 88 )
67.5
( min.43-max.82 )
TIA’s ( within the 12 hours ) 49 47 96
Crescendo TIA’s 35 64 99
Minor stroke 32 35 67
Major stroke 7 4 11
R. Moratto
Acute Carotid treatment Our experience : Immediate Results
Immediate Results CAS CEA CAS CEA
Technical success 100% 100% 100% 100%
Death 0 0 0 0
Worsening NIHSS 1.7 % 1.2 % 7.7 % 7.6 %
MI 1 pt 0 0 1 pt
Local complications
( hematoma) 2 pts 2 pts 1 pt 1 pt
TIA STROKE
R. Moratto
Acute Carotid treatment Our experience : Late Results
R. Moratto
Acute Treatment of Carotid Artery Disease Final consideration
La scienza è il capitano, e la pratica sono i soldati