Carotid Vascular Disease: Carotid Vascular Disease: Treatment options using Treatment options using

surgery and interventional surgery and interventional radiologyradiology

Emily Borod

MS3

Carotid Vascular DiseaseCarotid Vascular Disease

Stroke is 3rd leading cause of death in US (behind heart disease and cancer)

Mortality from acute event is 20% 50% of patients are alive after 5 years 4% of survivors require long-term skilled

nursing care 25% of survivors will have a second

neurologic event

Signs/symptoms of carotid Signs/symptoms of carotid vascular diseasevascular disease

TIA (Transient Ischemic Attacks): focal neurologic defects with resolution of symptoms within 24 hours

RIND (Reversible Ischemic Neurologic Deficit): transient neurologic defects lasting 24-72 hrs

Amaurosis fugax: temporary blindness in one eye, frequently described as “curtain coming down” due to microemboli in retina

CVA (Cerebrovascular accident): neurologic deficit with permanent brain damage

Evaluating carotid diseaseEvaluating carotid disease

Duplex Doppler ultrasonography Carotid Doppler ultrasonography Magnetic resonance angiography (MRA) Carotid angiography (gold standard)

Sensitivity/specificity of noninvasive tests to predict stenoses >70% is 83-86%/89-94%

Duplex Doppler ultrasonographyDuplex Doppler ultrasonography

MRA of carotid stenosisMRA of carotid stenosis

Carotid angiographyCarotid angiography

Treatment optionsTreatment options

Medical treatment (not as effective for more advanced disease)

Carotid endarterectomy (CEA) Nonsurgical carotid revascularization using

angioplasty and stenting

Treatment recommended for:– Asymptomatic pts with >60% stenosis– Symptomatic pts with >50% stenosis

Carotid endarterectomyCarotid endarterectomy

Performed through neck incision, usually along sternocleidomastoid muscle

Proximal and distal control of artery is obtained While patient is heparinized, internal and external

carotid arteries are clamped Longitudinal arteriotomy is performed, carotid

plaque is removed, and vessel is closed over a patch

Complications of carotid Complications of carotid endarterectomyendarterectomy

(perioperative mortality <0.5-3.0%, related level of (perioperative mortality <0.5-3.0%, related level of expertise of surgeons)expertise of surgeons)

Cardiac events Postoperative stroke Hyperperfusion

syndrome Nerve injury

Bleeding Infection Parotitis Re-stenosis

Postoperative cardiac eventsPostoperative cardiac events

Appropriate cardiac work-up is essential Because these patients have atherosclerotic

disease in the carotids, it must be assumed that they have atherosclerotic disease elsewhere

Exercise stress testing, dobutamine echocardiography, dipyridamole imaging, or coronary catherization should be used

Postoperative strokePostoperative stroke

Factors that contribute to postoperative stroke:– Plaque emboli– Platelet aggregates– Improper flushing– Poor cerebral protection– Relative hypotension

Hyperperfusion syndromeHyperperfusion syndrome

Cerebral hyperperfusion is the leading cause of intracerebral hemorrhage and seizures during the first two weeks following CEA

Causes changes in low-flow carotid vascular bed

Small vessels compensate by dilating, then cannot re-constrict properly and therefore cannot protect vascular bed

Nerve injuryNerve injury

Nerves at risk for injury during CEA include:– Vagus nerve– Recurrent laryngeal nerve– Facial nerve– Glossopharyngeal nerve– Hypoglossal nerve– Branches of trigeminal nerve

Re-stenosisRe-stenosis

Re-stenosis following CEA occurs in 20% of patients overall, and 2.6-10% at 5 years

Re-stenosis within 6 months is more common when smooth muscle cells are abundant in lesion and is less common when lesions are rich in lymphocytes and macrophages

Late re-stenosis results from progression of atherosclerotic disease

Carotid endarterectomyCarotid endarterectomy

Predictors of mortality Predictors of mortality following CEAfollowing CEA

Increased age Male sex (relative risk 1.58) Diabetes (RR 1.48) Systemic hypertension (RR 1.31) Smoking (RR 1.13)

Predictors of recurrence Predictors of recurrence following CEAfollowing CEA

Elevated cholesterol Systemic hypertension (RR 1.42) Smoking (RR 1.47)

Nonsurgical carotid Nonsurgical carotid revascularizationrevascularization

Percutaneous catheterization techniques have led to carotid angioplasty and stent placement

Less invasive (performed with local anesthesia and sedation)

Less likely to precipitate cardiac events Technique can also be used to repair

stenosis that is more cephalad

Technique used in Technique used in nonsurgical carotid repairnonsurgical carotid repair

Catheter with umbrella tip is inserted in stenotic carotid via femoral artery

Balloon is inflated to dilate artery Stent is placed in artery to maintain patency Filters are used to capture embolic particles

Examples of stents used in Examples of stents used in carotid revascularizationcarotid revascularization

Filters used in carotid repairFilters used in carotid repair

Pre- and post-stenting Pre- and post-stenting angiographyangiography

Risks of nonsurgical vascular Risks of nonsurgical vascular repairrepair

Plaques may be dislodged during procedure leading to neurologic events

Re-stenosis is common in long term follow-up (15%) and may be difficult to treat surgically

Dissection has been shown to occur in 5% of patients following stenting

More studies comparing CEA to nonsurgical repair must be completed

CEA vs stentingCEA vs stenting

Several studies have been carried out or are in progress to compare CEA and repair of carotid artery disease using interventional radiology

Because of the potentially significant and lasting damage from a stroke and the relative success of CEA, studies comparing the two treatment options have been somewhat slow to be carried out

Most of the early studies compare the two techniques in specific patient groups (i.e. elderly patients or poor surgical candidates)

WALLSTENT trialWALLSTENT trial

219 patients with symptomatic stenosis Carotid arteries were 60-90% occluded Patients were randomly assigned to receive CEA

or angioplasty and stenting (without protective filter device)

1-yr follow-up showed significantly higher rate of post-procedure stroke with angioplasty and stenting group compared to CEA group (12.2 vs 3.6%)

SAPPHIRE studySAPPHIRE study

CEA vs carotid stenting with protective filter device

334 patients with concurrent conditions that made them poor surgical candidates

Symptomatic carotid stenosis of ≥50% or asymptomatic stenosis of ≥80%

Primary end-point: major cardiovascular event within one year (death, stroke, MI)

Results of SAPPHIRE studyResults of SAPPHIRE study

Major cardiovascular events within one year were more common in CEA group than in angioplasty and stenting group (20.1% compared to 12.2%)

Carotid revascularization was repeated within one year in fewer patients with stents than in patients who underwent CEA (0.6% and 4.3%, p=.04)

Stenting vs CEA in elderly patientsStenting vs CEA in elderly patients

Retrospective study of pts ≥75 years old who had been treated for carotid stenosis

53 pts who had undergone stenting between June 2001 and April 2004 were compared to 110 pts who had undergone CEA between January 1997 and December 2001

Primary outcome was MI or major, minor, or fatal stroke within one month of treatment

Results of CEA vs stenting in Results of CEA vs stenting in elderly patients elderly patients

Incidence of major or minor stroke within 30 days of treatment was significantly higher in stenting than in CEA group (11.3% to 1.8%, P<0.05)

Incidence of major stroke within 30 days was similar in the two groups, but incidence of minor strokes was higher in stenting group (7.5% vs 0%, P<0.05)

Protective embolic filter devices were used in this trial

CAVATAS trialCAVATAS trial

504 pts with carotid stenosis were randomly assigned to CEA or angioplasty and stenting

Results showed similar major risks and effectiveness of the two treatment options

Outcomes following surgery were worse than outcomes reported in major trials evaluating carotid surgery, supporting the fact that there is a great deal of variability in outcome depending on surgeon expertise

ConclusionConclusion

Carotid vascular disease is prevalent in the US and results in significant mortality and morbidity when untreated

Results of trials comparing the invasive treatment options are ongoing and have shown somewhat conflicting results

Studies support the use of angioplasty and stenting in certain patient populations

Conclusion Conclusion

Patients with carotid stenosis who are likely to benefit more from carotid angioplasty and stenting than from CEA include pts with significant comorbidities that make them poor surgical candidates

Elderly pts may be at higher risk of having a minor stroke within 30 days following stenting than CEA

The use of protective embolic filters is important in the outcome following angioplasty and stenting

Conclusion Conclusion

Stenting is a promising option for treating carotid stenosis in patients who are high-risk surgical candidates

More studies comparing the revascularization procedures are necessary before treatment recommendations can be refined

Attention to long-term results of stenting should also be compared to long-term CEA results

References References Alhaddad, I.A.; Carotid Artery Surgery vs. Stent: A Cardiovascular

Perspective; Catheterization and Cardiovascular Interventions; 63:377-384 (2004).

Brott, T.G., et al; Carotid Revascularization for Prevention of Stroke: Carotid Endarterectomy and Carotid Artery Stenting; Mayo Clinic Proceedings, 79(9), 1197-1208 (2004).

Eskandari, M.K., et al; Does Carotid Stenting Measure Up to Endarterectomy? A Vascular Surgeon’s Experience; Archives of Surgery, Vol.139, pp. 734-738 (2004).

Greelish, J.P., et al; Nonsurgical carotid revascularization; UpToDate, www.uptodate.com.

Greelish, J.P., et al; Carotid endarterectomy: Preoperative evaluation, surgical technique, and complications; UpToDate, www.uptodate.com.

References References

Phatouros, C.C., et al; Carotid Artery Stent Placement for Atherosclerotic Disease: Rationale, Technique, and Current Status; Radiology; Oct 2000.

Kastrup, A., et al; Comparison of angioplasty and stenting with cerebral protection versus endarterectomy for treatment of internal carotid artery stenosis in elderly patients; Journal of Vascular Surgery, Nov. 2004.

Kirsch, E.C., et al; Carotid Arterial Stent Placement: Results and Follow-up in 53 Patients; Radiology; Sept. 2001.

Yadav, J.S., et al; Protected Carotid-Artery Stenting versus Endarterectomy in High-Risk Patients; The New England Journal of Medicine, 351:15 (2004).