Indications for CASvs

Surgical_Medical

Marianne BrodmannDivision of Angiology Graz

Therapeutic Options

• Medical Management

• Carotid Endarterectomy_CEA

• Carotid Artery Stenting _CAS

What to prevent?

Lausanne Stroke Registry

Therapeutic Progress

Therapeutic Progress

Western Countries stroke 3rd most case of death and number 1 condition associated with permanent disability

Carotid artery stenosis responsible for 10-20% of all ischemic cerebral events

Based mostly on atherosclerotic disease, typically affection of origin of carotid internal artery

Symptomatic stenosis means

Amaurosis fugax, TIA or stroke affecting the corresponding territory in the proceeding 6 mths

The greater the severity of stenosis, the greater the risk of recurrent ischemic event

Roffi M. Herz 2008;33:490-7.

Therapeutic Progress

Risk of recurrence in territory of symptomatic CA stenosis [NASCET1]

>70% 26% over 2 years (13%/year)50-69% 18.5% over 5 years (4.4%/year)

Risk of recurrence in territory of asymptomatic CA stenosis [ACST2]

>60% yearly risk is ~2%may increase in elderly patients to 3-4%/year

contralateral CA stenosis/occlusioncarotid plaque heterogenitypoor collateral blood supplycardiac or medical illnesses

1 Inzitari D et al. NEJM 2000;342:1693-700.2 Halliday A et al Lancet2004;363:1491-502.

Medical Management

Kragsterman B et al. Stroke 2006;37:2886-91.

Aggressive risk factor Management !

Medical Management/Best Medical Treatment

SVS Guidelines

Symptomatic and asymptomatic patients with low grade stenoses

<50% symptomatic<60% asymptomatic

BEST MEDICAL TREATMENT [Grade I]

Hobson RW J Vasc Surg 2008;48:480-6.

EVIDENCE

2 RCT´s with 5950 patients [NASCET/ECST]

Patients with low-grade stenosis (NASCET <50%, ESCT <70%)CEA elevated the risk for disabling stroke and death

at 20%

Best Medical Treatment

Barnett HJM NEJM. 1998;339:1415-25.

Evidence

SurgeryMedical

Best Medical Treatment

Antiplatelet Therapy

Recommended indefinitely in all patients with carotid stenosis, irrespective of symptoms

Antithrombotic Trialists´Collaboration. BMJ 2002;324:71-86.

Best Medical Treatment

Antiplatelet Therapy

Recent symptomatic CA stenosis

Aspirin+Clopidogrel>>Aspirin ???[Markus HS Circulation 2005;111:2233-40]

Best Medical Treatment

Lipids

Heart Protection Study20000 patients (asymptomatic CA stenosis included)

40 mg Simvastatin/Placebo

Decline of LDL Cholesterol per 29% associated with a 24% RR for composite endpoint major vascular events [25% RR for stroke]

Independent of Baseline Cholesterol

Indication for CEA /CAS reduced for 50% in existing CA stenosis

Best Medical Treatment

Lipids

4731 patients with recent stroke or TIA, without CAD on high-dose atrovastatin

80 mg atrovastatin daily

Influence of aggressive statin therapy

Amarenco P et al. NEJM 2006;355:549-59.

Best Medical Treatment

Arterial Hypertension

5-6 mmHG Reduction systolic blood pressure2-3 mmHG Reduction diastolic blood pressure

[Collins R. Lancet 1990;335:827-38]

Effect independent of age, even above 80 yrs, and isolated arterial hypertension

[Staessen JA. Lancet 2001;358:1305-15.]

Symptomatic patients < 5 years/ PROGRESS[Lancet 2001:358:1033-41]

40% RR

28% RR

RR 28%

Carotid Endarterectomy_CEA

SVS Guidelines

Symptomatic patients with stenosis > 50%Asymptomatic patients with stenosis > 60%

[as long as perioperative risk is low]

[Grade I]

Hobson RW J Vasc Surg 2008;48:480-6.

Evidence

Hobson RW J Vasc Surg 2008;48:480-6.

NASCET Grade of stenosis 50-69% 5-year FU any ipsilateral 15.7% vs 22.2%= 15 patients to prevent an ipsilateral stroke

Grade of stenosis 70-99% 2-year FU any ipsilateral 9% vs 26%= 6 patients to prevent an ipsilateral stroke

disabling or fatal 13.1% vs 2.5%

ESCT Grade of stenosis 70-99% similiar results 3-year FU any ipsilateral 2.8 vs 16.8%= 7 patients to prevent an ipsilateral stroke

Carotid Endarterectomy_CEA

Hobson RW J Vasc Surg 2008;48:480-6.

… is not supported by high quality evidence but rather by very low quality evidence..

NASCET_ Exclusion criteria

Life expectancy <5 years and significant co-morbidityAge >79 yearsproceeding ipsilateral endarterctomyAngiography of both carotid arteries and intercerebral

arteries not possible

Experience of surgeon and surgical center

Carotid Endarterectomy_CEA

Evidence

Evidence

Hobson RW J Vasc Surg 2008;48:480-6.

Ulcerated plaques with no flow limitation ?????

Carotid Endarterectomy_CEA

Carotid Endarterectomy_CEA

SVS Guidelines

Symptomatic patients with stenosis > 50%Asymptomatic patients with stenosis > 60%

[as long as perioperative risk is low]

[Grade I]

Hobson RW J Vasc Surg 2008;48:480-6.

Evidence

1 Hobson RW J Vasc Surg 2008;48:480-6.2 Chambers BR Cochrane Rev 20053 Halliday A Lancet 2004,363:1491-1502

3 RCT´s with 5223 patients 2

> 50% Veteran affairs Cooperative Study (1986)> 60% ACAS/ACST (1995/2004)

ACST3

5-year stroke risk 3.8% vs 11% [gain 7.2%](-perioperative events)

disabling/fatal 1.6% vs 5.3% [gain 3.7%]

5-year stroke risk 6.4% vs 11.8% [gain 5.4%](+perioperative events)

disabling/fatal 3.5% vs 6.1% [gain 2.5%]only fatal 2.1% vs 4.2% [gain 2.1%]

ACST3

Benefits remained significantly separately men/women with stenosis graded >70%,80%,90% (duplex) younger < 65 years and between 65-74 years

Carotid Endarterectomy_CEA

Carotid Endarterectomy_CEA

Limitations

1Roffi M. Herz 2008;33:490-7.2Birkmeyer JD et al. NEJM 2003;349:2117-27.

Benefits of CEA in RCT´s conveyed by low perioperative complication rates[high volume surgeons and low risk patients]

Patients at risk to die [>80 yrs, co-morbidities….]not included

Results of CEA observed in trials may not be reproduced in clinical practice[overall mortality rate in hospitals taking part in NASCET/ACAS was 1.4% vs 0.6 or 0.1in the trials]

Low-volume hospitals perioperative mortality rate 2.5% [USA 136000 CEA, mean volume 15 procedures/yr/; 1/3 by mean volume 5/yr2]

Carotid Artery Stenting (CAS)

SVS Guidelines

Symptomatic patients with stenosis > 50%[+high perioperative risk]

[Grad II, low quality evidence]

Good defined by authors: high anatomic risk

proceeding CEA with recurrent stenosisproceeding ipsilateral radiation therapy with persistent skin lesionsproceeding local surgery (neckdissection….) stenosis of common carotid artery below claviclecontralateral lesion of vocal cordtracheostoma

Hobson RW J Vasc Surg 2008;48:480-6.

Authors have not well defined„ high medical risk“renal failureextremly low ejection fractionCOPD with necessity of constant oxygen therapy…

Carotid Artery Stenting (CAS)

Evidence

Hobson RW J Vasc Surg 2008;48:480-6.2 Murad HM J Vasc Surg 2008;48:487-93

10 RCT´s with 3182 patients2

Majority symptomatic, 1 Trial high surgical risk

Learning curve ??

•617 patients /5 trials with low patient numbers•Early Trials •Multi Center with low patient number/center

Carotid Artery Stenting (CAS)

Evidence

Hobson RW J Vasc Surg 2008;48:480-6.2 Murad HM J Vasc Surg 2008;48:487-93

10 RCT´s with 3182 patients2

Majority symptomatic, 1 trial high surgical risk

Carotid Artery Stenting (CAS)

SVS Guidelines

asymptomatic patients

Recommendation against stenting for asymptomatic disease

[Grad I, low quality evidence]

Hobson RW J Vasc Surg 2008;48:480-6.

Carotid Artery Stenting (CAS)

Evidence

Hobson RW J Vasc Surg 2008;48:480-6.

No RCT´s comparing CAS with medical management

2 RCT´s compare CAS mit CEAsmall number of patients (323) and events (18)(all events in SAPHIRE)

Carotid Artery Stenting (CAS)Evidence

Deredyn CP. Stroke 2007;38:715-20.

Majority of data originate from Registries

Periprocedural stroke and death rates > 3% (bar at large CEA trials)

Carotid Artery Stenting (CAS)

Strengths/Limitations

StrengthEndovascular approach is less invasiveMay treat lesions that are not accessible to surgery

LimitationsPoor outcomes are related to challenging anatomies

[steep aortic arch, severe tortuosity…. ]Inability to place an EPDSevere circumferential calicificationSevere renal failure

Thank you for your attention!