cerebrovascular disease murray shames, m.d. assistant professor of surgery and radiology division of...
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Cerebrovascular DiseaseCerebrovascular Disease
Murray Shames, M.D.Murray Shames, M.D.Assistant Professor of Surgery and RadiologyAssistant Professor of Surgery and Radiology
Division of Vascular and Division of Vascular and Endovascular SurgeryEndovascular Surgery
Cerebrovascular DiseaseCerebrovascular Disease
FundamentalsFundamentals:
Stroke is the third leading Stroke is the third leading
cause of death in the USA cause of death in the USA
(200 000)(200 000)
Incidence 160/100 000Incidence 160/100 000
HTN most common causeHTN most common cause
30% associated with 30% associated with
extracranial carotid stenosisextracranial carotid stenosis
Significant disabilitySignificant disability $7.5 billion (1976)$7.5 billion (1976)
Cerebrovascular DiseaseCerebrovascular Disease
Relative Risk for Ischemia:Relative Risk for Ischemia:
Age:Age: 10/100,000 < 45 yr10/100,000 < 45 yr 1000/100,000 > 75 yr1000/100,000 > 75 yr
Hypertension: 6xHypertension: 6x Atrial fibrillation: 6xAtrial fibrillation: 6x Prior stroke/TIA: 5 xPrior stroke/TIA: 5 x Asymptomatic carotid bruit: 3xAsymptomatic carotid bruit: 3x Smoking: 2xSmoking: 2x
Cerebrovascular DiseaseCerebrovascular Disease
Pathology:Pathology: Carotid Artery LesionCarotid Artery Lesion
10% fibromuscular 10% fibromuscular dysplasia, intimal dissection, dysplasia, intimal dissection,
inflammatory lesions, inflammatory lesions, radiationradiation
90 % atherosclerosis90 % atherosclerosis
Cerebrovascular DiseaseCerebrovascular Disease
Atherosclerosis:Atherosclerosis:
Similar L-R distributionSimilar L-R distribution
40% of lesions at proximal ICA40% of lesions at proximal ICA
20% of lesions at proximal vertebral20% of lesions at proximal vertebral
Aortic arch disease in 10% of Aortic arch disease in 10% of patientspatients
Cerebrovascular DiseaseCerebrovascular Disease
Cardiac embolus Cardiac embolus atrial fibrillation atrial fibrillation heart valve diseaseheart valve disease
Rupture of intracranial aneurysmRupture of intracranial aneurysm Intra-cranial hemorrhageIntra-cranial hemorrhage Carotid artery dissectionCarotid artery dissection Carotid aneurysmCarotid aneurysm Fibromuscular dysplasiaFibromuscular dysplasia RadiationRadiation
Other causes of stroke:Other causes of stroke:
Cerebrovascular DiseaseCerebrovascular Disease
Fibromuscular Dysplasia:Fibromuscular Dysplasia:
Carotid second most common site of diseaseCarotid second most common site of disease 92% Women92% Women 30% of patients intracranial aneurysms30% of patients intracranial aneurysms Degenerative process involving long, unbranched Degenerative process involving long, unbranched
medium sized vesselsmedium sized vessels Hormonal, mechanical, unusual distribution of vasa Hormonal, mechanical, unusual distribution of vasa
vasorumvasorum HistologyHistology
Intimal fibroplasiaIntimal fibroplasiaMedial HyperplasiaMedial HyperplasiaMedial Fibroplasia (most common)- replacement of Medial Fibroplasia (most common)- replacement of media with dense fibrous connective tissuemedia with dense fibrous connective tissuePerimedial dysplasia (renals)Perimedial dysplasia (renals)
Cerebrovascular DiseaseCerebrovascular Disease
Carotid Dissection:Carotid Dissection:
Traumatic Traumatic disruption of disruption of intimaintima Compression Compression of true lumenof true lumen
Cerebrovascular DiseaseCerebrovascular Disease
Pathogenesis of Atherosclerosis:Pathogenesis of Atherosclerosis:
Intimal injury (hemodynamics)Intimal injury (hemodynamics) Nodular deposition of fat in arterial intimaNodular deposition of fat in arterial intima Associated inflammatory response – fibroblast, Associated inflammatory response – fibroblast, smooth muscle cell proliferationsmooth muscle cell proliferation Slow accumulation of lipoproteinsSlow accumulation of lipoproteins
Calcium precipitation in the primary fatty plaque.Calcium precipitation in the primary fatty plaque.
Cerebrovascular DiseaseCerebrovascular Disease
Hemodynamics:Hemodynamics:
High shear stressHigh shear stress Turbulent flowTurbulent flow Flow seperationFlow seperation Propensity for outer wallPropensity for outer wall
opposite flow divideropposite flow divider
Cerebrovascular DiseaseCerebrovascular Disease
Atherosclerosis:Atherosclerosis:
Flow reducingFlow reducing EmbolicEmbolic
ClotClotPlateletsPlateletsCholesterol debrisCholesterol debris
ThrombosisThrombosis
Cerebrovascular DiseaseCerebrovascular Disease
Complex Carotid Plaques:Complex Carotid Plaques:
CalcificationCalcification Loss of intimal Loss of intimal
continuitycontinuity Ulcer formationUlcer formation Subintimal necrosisSubintimal necrosis Plaque hemorrhagePlaque hemorrhage
Cerebrovascular DiseaseCerebrovascular Disease
Presentation:Presentation:
AsymptomaticAsymptomatic
Transient Ischemic AttacksTransient Ischemic Attacks
Cerebral InfarctionCerebral Infarction
Cerebrovascular DiseaseCerebrovascular Disease
Asymptomatic:Asymptomatic:
Natural history- Natural history- progression of progression of diseasedisease >80% stenosis >80% stenosis associated with associated with 35% risk of 35% risk of symptoms or symptoms or occlusion in 6 occlusion in 6 monthsmonths
Cerebrovascular DiseaseCerebrovascular Disease
Surveillance:Surveillance:
Duplex scan q 6-Duplex scan q 6-12 months12 months
Cerebrovascular DiseaseCerebrovascular Disease
reversible, reversible, painless painless neurologic neurologic deficit, lasting deficit, lasting 1-5 minutes1-5 minutes Complete Complete recovery < 24 hrecovery < 24 h
Transient Ischemic Attacks:Transient Ischemic Attacks:
Cerebrovascular DiseaseCerebrovascular Disease
a harbinger of stroke (30-40% of patients with a harbinger of stroke (30-40% of patients with surgically accessible carotid stenosis)surgically accessible carotid stenosis)
No loss of consciousness - syncopeNo loss of consciousness - syncope Amaurosis fugax: embolus to ipsilateral retinal Amaurosis fugax: embolus to ipsilateral retinal
arteryartery AphasiaAphasia Contralateral paralysis, paresis, paresthesiasContralateral paralysis, paresis, paresthesias Stroke rate at 1 ,3 , 5 years 23%, 27%, 45%Stroke rate at 1 ,3 , 5 years 23%, 27%, 45% Crescendo TIA’s/ Stroke in evolutionCrescendo TIA’s/ Stroke in evolution
Transient Ischemic Attacks:Transient Ischemic Attacks:
Cerebrovascular DiseaseCerebrovascular Disease
Stroke:Stroke:
Brain infarction 50% preceded by TIA Embolic or thrombosis with inadequate collaterals Symptoms greater than 24 hours 1/3 resolve, 1/3 deteriorate, 1/3 remain the same
Cerebrovascular DiseaseCerebrovascular Disease
Sequalae of Internal Carotid Artery Occlusion:Sequalae of Internal Carotid Artery Occlusion:
propagation of thrombus to propagation of thrombus to intracranial arteriesintracranial arteries embolization of thrombusembolization of thrombusboth can result in cerebral both can result in cerebral infarctioninfarctionoutcome depends on outcome depends on adequacy of collateral flow:adequacy of collateral flow:
Circle of WillisCircle of Willis
Cerebrovascular DiseaseCerebrovascular Disease
‘ ‘VIRULENCE’ OF CAROTID ARTERY DISEASE VIRULENCE’ OF CAROTID ARTERY DISEASE BASED ON CLINICAL SYMPTOMSBASED ON CLINICAL SYMPTOMS
Clinical entity Risk of subsequent strokeClinical entity Risk of subsequent stroke
Recent (< 4 mo) strokeRecent (< 4 mo) stroke High (10-15%)High (10-15%)Recent hemispheric TIA Recent hemispheric TIA unstable unstable
plaqueplaqueRecent amaurosis fugaxRecent amaurosis fugaxPrevious stroke, TIA, amaurosis Previous stroke, TIA, amaurosis Silent infarct CT or MRISilent infarct CT or MRIAsymptomatic bruitAsymptomatic bruit Low (1-3%)Low (1-3%)Non-hemispheric symptomsNon-hemispheric symptomsHypertensionHypertension
Cerebrovascular DiseaseCerebrovascular Disease
Clinical Evaluation:Clinical Evaluation:
History and Physical Exam
Degree, duration of symptoms
Extent of recovery
Presence of infarction on CT/MRI
Cerebrovascular Imaging
Duplex
Angiography
MRA
Cerebrovascular DiseaseCerebrovascular Disease
Velocity Criteria: PSV, ICA/CCA Ratio:Velocity Criteria: PSV, ICA/CCA Ratio:
>50 % stenosis: PSV > 125 cm/sec>50 % stenosis: PSV > 125 cm/sec
ICA/CCA ratio>2.0ICA/CCA ratio>2.0 >60% stenosis: PSV > 230-270 cm/sec>60% stenosis: PSV > 230-270 cm/sec
ICA/CCA ratio>3.5ICA/CCA ratio>3.5 >70 % stenosis: PSV > 290-325 cm/sec>70 % stenosis: PSV > 290-325 cm/sec
ICA:CCA ratio>4.0ICA:CCA ratio>4.0 >80 % stenosis: EDV > 140 cm/sec>80 % stenosis: EDV > 140 cm/sec
Cerebrovascular DiseaseCerebrovascular Disease
v
The Doppler
Principle
skinfo
f
Doppler Measurement of Blood Flow Velocity:Doppler Measurement of Blood Flow Velocity:
Sample Volume
VelocityProfile
Cerebrovascular DiseaseCerebrovascular Disease
Duplex Ultrasound:Duplex Ultrasound:
Cerebrovascular DiseaseCerebrovascular Disease
Criteria of carotid stenosis:Criteria of carotid stenosis:
ICA STENOSIS
DUPLEX SCAN MRA
<50% DR PSV < 125 cm/sICA/CCA ratio < 2
< 50% DR
50-74% DR PSV > 125 cm/sEDV < 125 cm/s
2 < ICA/CCA ratio < 4
50-74% DR
75-99% DR PSV > 300 cm/sEDV > 125 cm/s
ICA/CCA ratio > 4
75-99% DRshort (<3 cm)
flow gap
No ICA flowCCA EDV = 0
Long (>3 cm) flow gap
No intracranial ICA signal
Occlusion
Cerebrovascular DiseaseCerebrovascular Disease
Contrast Angiography:Contrast Angiography:
High grade ICA stenosis
Cerebrovascular DiseaseCerebrovascular Disease
High Resolution B-mode Imaging:High Resolution B-mode Imaging:
proximalproximal
Cerebrovascular DiseaseCerebrovascular Disease
Magnetic Resonance Angiography:Magnetic Resonance Angiography:
Cerebrovascular DiseaseCerebrovascular Disease
Magnetic Resonance Angiography:Magnetic Resonance Angiography:
Cerebrovascular DiseaseCerebrovascular Disease
The ultimate goal of vascular testing is to The ultimate goal of vascular testing is to identify identify clinically significantclinically significant carotid disease, carotid disease, so that treatment can be applied and risk of so that treatment can be applied and risk of stroke reduced.stroke reduced.
Cerebrovascular DiseaseCerebrovascular Disease
Benefit of CEA for Asymptomatic Stenosis:Benefit of CEA for Asymptomatic Stenosis:
Annual stroke riskAnnual stroke risk Medical tx CEA p valueMedical tx CEA p value
VA 1993 (n=444) 2.4 % 1.2 % > 0.05VA 1993 (n=444) 2.4 % 1.2 % > 0.05
ACAS 1995 (n=1662) 2.2 % 1.0 % 0.004ACAS 1995 (n=1662) 2.2 % 1.0 % 0.004
Cerebrovascular DiseaseCerebrovascular Disease
Benefit of CEA for Symptomatic Stenosis:
Annual stroke risk Medical tx CEA p value
NASCET 1991> 70 % stenosis 13 % 4.5 % < 0.001
NASCET 199850 - 70 % stenosis 4.4 % 3.1 % 0.045
Cerebrovascular DiseaseCerebrovascular Disease
Absolute ReductionAbsolute Reduction Symptomatic patientsSymptomatic patients in Stroke Riskin Stroke Risk
NASCET: > 70% DR NASCET: > 70% DR 17% @ 2 yr17% @ 2 yr
NASCET: 50-59%NASCET: 50-59% 10% @ 5 yr 10% @ 5 yr
ECST: > 70% DR ECST: > 70% DR 12% @ 3 yr12% @ 3 yr
Asymptomatic patientsAsymptomatic patients
ACAS: > 60% DRACAS: > 60% DR 6.3% @ 5 yr6.3% @ 5 yr
** multicenter, random assignment - angiography controlledmulticenter, random assignment - angiography controlled
Results of surgery vs. medical therapy:Results of surgery vs. medical therapy:
Cerebrovascular DiseaseCerebrovascular DiseaseCerebrovascular SymptomsCerebrovascular Symptoms
Carotid Territory TIACarotid Territory TIA StrokeStroke
Carotid Duplex TestingCarotid Duplex Testing ECG, CT Scan, MRI/MRAECG, CT Scan, MRI/MRACerebral AngiographyCerebral Angiography(-)(-)
>60% ICA Stenosis>60% ICA Stenosis
Consider forConsider forCarotid EndarterectomyCarotid Endarterectomy
IsolatedIsolatedBifurcationBifurcation
DiseaseDisease
Combined Carotid Combined Carotid Vertebral–Subclavian Vertebral–Subclavian
DiseaseDiseaseASSESSASSESS
OPERATIVE RISKOPERATIVE RISK
TransluminalTransluminalAngioplasty/StentAngioplasty/Stent
LowLow HighHigh
Cerebrovascular DiseaseCerebrovascular Disease
Asymptomatic – Carotid BruitAsymptomatic – Carotid Bruit
<60-70% Stenosis<60-70% Stenosis >70-80% Stenosis>70-80% Stenosis
Medical TreatmentMedical Treatment? Disease Progression? Disease Progression
?Contralateral ICA Occlusion?Contralateral ICA OcclusionAssess life expectancyAssess life expectancyAssess Operative RiskAssess Operative Risk- Control of ASO risk factorsControl of ASO risk factors
- Aspirin or ClopidogrelAspirin or Clopidogrel- Surveillance Surveillance
Isolated Isolated BifurcationBifurcation
DiseaseDiseaseMedical Rx,Medical Rx,Carotid stentCarotid stent
Carotid Carotid EndarterectomyEndarterectomy
High RiskHigh RiskGood CandidateGood Candidate
Cerebrovascular DiseaseCerebrovascular Disease
Carotid Endarterectomy:Carotid Endarterectomy:
Considerations:Considerations: AnesthesiaAnesthesia
GeneralGeneral RegionalRegional
ShuntShunt PatchPatch
Cerebrovascular DiseaseCerebrovascular Disease
Carotid Endarterectomy:Carotid Endarterectomy:
Cerebrovascular DiseaseCerebrovascular Disease
Carotid Endarterectomy:Carotid Endarterectomy:
Cerebrovascular DiseaseCerebrovascular Disease
Carotid Endarterectomy:Carotid Endarterectomy:
Cerebrovascular DiseaseCerebrovascular Disease
Cerebrovascular DiseaseCerebrovascular Disease
Results of Carotid Endarterectomy:Results of Carotid Endarterectomy:ClinicalClinical Death/ Death/ % of CEAs % of CEAsSeries Series # CEAs Stroke w/o Angio # CEAs Stroke w/o Angio
USFUSF 350 0.6%/0.9% 350 0.6%/0.9% 68% 68%
Samson Samson 603 0.2%/1.6% 603 0.2%/1.6% 93% 93%
MelissanoMelissano 728 0.4%/1.6% 728 0.4%/1.6% 86% 86%
LogasonLogason 229 1.2%/2.2% 229 1.2%/2.2% 80% 80%
AscherAscher 903 0.7%/0.7% 903 0.7%/0.7% 94% 94%
Cerebrovascular DiseaseCerebrovascular Disease
Complications:Complications:
Cranial nerve injury up to 4-16%Cranial nerve injury up to 4-16% Stroke 1-6%Stroke 1-6% Hemorrhage/ hematoma 1-5%Hemorrhage/ hematoma 1-5% Mortality < 1%Mortality < 1% Restenosis < 5% (myointimal hyperplasia)Restenosis < 5% (myointimal hyperplasia)
Cerebrovascular DiseaseCerebrovascular Disease
Carotid Artery StentingCarotid Artery Stenting
Cerebrovascular DiseaseCerebrovascular Disease
Outcome of Carotid Stent-Assisted Outcome of Carotid Stent-Assisted Angioplasty versus Open Surgical Repair for Angioplasty versus Open Surgical Repair for
Recurrent Carotid StenosisRecurrent Carotid Stenosis
Outcome of Carotid Stent-Assisted Outcome of Carotid Stent-Assisted Angioplasty versus Open Surgical Repair for Angioplasty versus Open Surgical Repair for
Recurrent Carotid StenosisRecurrent Carotid Stenosis
Andrew N. Bowser, MDAndrew N. Bowser, MDDennis F. Bandyk, MDDennis F. Bandyk, MD
Avery Evans, MDAvery Evans, MDMichael Novotney, MDMichael Novotney, MD
Martin R. Back, MDMartin R. Back, MDBrad L. Johnson, MDBrad L. Johnson, MD
Murray L. Shames, MDMurray L. Shames, MD
Division of Vascular & Endovascular Surgery Division of Vascular & Endovascular Surgery University of South Florida College of Medicine University of South Florida College of Medicine
Tampa, FloridaTampa, Florida
Division of Vascular & Endovascular Surgery Division of Vascular & Endovascular Surgery University of South Florida College of Medicine University of South Florida College of Medicine
Tampa, FloridaTampa, Florida
Cerebrovascular DiseaseCerebrovascular Disease
1010-year Concurrent Review (1993-2002)-year Concurrent Review (1993-2002) • CAS(1997-2002): 50 patients (52 arteries)CAS(1997-2002): 50 patients (52 arteries)• Redo-CEA: 27 patientsRedo-CEA: 27 patients
1010-year Concurrent Review (1993-2002)-year Concurrent Review (1993-2002) • CAS(1997-2002): 50 patients (52 arteries)CAS(1997-2002): 50 patients (52 arteries)• Redo-CEA: 27 patientsRedo-CEA: 27 patients
CAS CAS CAS CAS Re-do CEARe-do CEARe-do CEARe-do CEA
Age:Age: 66.5 66.5 ± 11± 11 70.2 70.2 ±± 8 p<0.01 8 p<0.01Men:Men: 19 (70%) 19 (70%) 35 (70%) 35 (70%)
Co-morbid Conditions:Co-morbid Conditions:HTNHTN 24 (88%) 24 (88%) 44 (88%) 44 (88%) p NSp NSCADCAD 13 (48%) 13 (48%) 31 (62%) 31 (62%) p NSp NSSmoker 19 (70%)Smoker 19 (70%) 33 (66%) 33 (66%) p NSp NS LipidsLipids 16 (59%) 16 (59%) 35 (70%) 35 (70%) p NSp NSPVDPVD 12 (24%) 12 (24%) 24 (48%) p NS 24 (48%) p NSDMDM 8 (30%) 8 (30%) 8 (16%) 8 (16%) p = .11p = .11
Age:Age: 66.5 66.5 ± 11± 11 70.2 70.2 ±± 8 p<0.01 8 p<0.01Men:Men: 19 (70%) 19 (70%) 35 (70%) 35 (70%)
Co-morbid Conditions:Co-morbid Conditions:HTNHTN 24 (88%) 24 (88%) 44 (88%) 44 (88%) p NSp NSCADCAD 13 (48%) 13 (48%) 31 (62%) 31 (62%) p NSp NSSmoker 19 (70%)Smoker 19 (70%) 33 (66%) 33 (66%) p NSp NS LipidsLipids 16 (59%) 16 (59%) 35 (70%) 35 (70%) p NSp NSPVDPVD 12 (24%) 12 (24%) 24 (48%) p NS 24 (48%) p NSDMDM 8 (30%) 8 (30%) 8 (16%) 8 (16%) p = .11p = .11
Cerebrovascular DiseaseCerebrovascular Disease
CASCASCASCASRe-do CEARe-do CEARe-do CEARe-do CEA
Number:Number: 27 27 52 52Indication:Indication: --SymptomaticSymptomatic 17 (63%)17 (63%) 31 (60%) 31 (60%) p NSp NS
TIATIA 4 (15%) 4 (15%) 19 (37%) 19 (37%)
CVA 10 (37%)CVA 10 (37%) 7 (13%) 7 (13%) p = .02p = .02BothBoth 3 (11%) 3 (11%) 5 (10%) 5 (10%)
--AsymptomaticAsymptomatic 10 (37%) 21 (40%)10 (37%) 21 (40%) p NS p NS
Mean Interval Mean Interval to re-intervention:to re-intervention: 83 83 ± 14± 14 mo. mo. 50 50 ±± 8 mo. 8 mo. p < 0.01p < 0.01
Early (<36m) RCS:Early (<36m) RCS: 10 (37%)10 (37%) 33 (63%) 33 (63%) p = 0.03p = 0.03
Number:Number: 27 27 52 52Indication:Indication: --SymptomaticSymptomatic 17 (63%)17 (63%) 31 (60%) 31 (60%) p NSp NS
TIATIA 4 (15%) 4 (15%) 19 (37%) 19 (37%)
CVA 10 (37%)CVA 10 (37%) 7 (13%) 7 (13%) p = .02p = .02BothBoth 3 (11%) 3 (11%) 5 (10%) 5 (10%)
--AsymptomaticAsymptomatic 10 (37%) 21 (40%)10 (37%) 21 (40%) p NS p NS
Mean Interval Mean Interval to re-intervention:to re-intervention: 83 83 ± 14± 14 mo. mo. 50 50 ±± 8 mo. 8 mo. p < 0.01p < 0.01
Early (<36m) RCS:Early (<36m) RCS: 10 (37%)10 (37%) 33 (63%) 33 (63%) p = 0.03p = 0.03
Nine CAS patients enrolled in Clinical TrialsNine CAS patients enrolled in Clinical Trials
Cordis – Feasibility trialCordis – Feasibility trial 1 pt. 1 pt.
Archer-1(no distal protection)Archer-1(no distal protection) 2 pts 2 pts Archer-2 (distal protection)Archer-2 (distal protection) 3 pts 3 pts
Crest–Lead-in (distal protection)Crest–Lead-in (distal protection) 3 pts 3 pts
Nine CAS patients enrolled in Clinical TrialsNine CAS patients enrolled in Clinical Trials
Cordis – Feasibility trialCordis – Feasibility trial 1 pt. 1 pt.
Archer-1(no distal protection)Archer-1(no distal protection) 2 pts 2 pts Archer-2 (distal protection)Archer-2 (distal protection) 3 pts 3 pts
Crest–Lead-in (distal protection)Crest–Lead-in (distal protection) 3 pts 3 pts
Cerebrovascular DiseaseCerebrovascular Disease
17 CAS pts not surgical candidates: 33%
- Surgically-inaccessible high lesions (n=8)
- Severe disabling medical comorbidity (n=4)
- Neck irradiation (n=3)
- Other (RCS with CN injury) (n=2)
Option of redo-CEA or CAS (n=35) 3 Redo-CEA Pts Deemed Not CAS
Candidates
17 CAS pts not surgical candidates: 33%
- Surgically-inaccessible high lesions (n=8)
- Severe disabling medical comorbidity (n=4)
- Neck irradiation (n=3)
- Other (RCS with CN injury) (n=2)
Option of redo-CEA or CAS (n=35) 3 Redo-CEA Pts Deemed Not CAS
Candidates
Soft thrombus
Cerebrovascular DiseaseCerebrovascular Disease
30-Day Procedural Outcomes 30-Day Procedural Outcomes
Mortality Ipsilateral Stroke/TIA
CN Deficit
Hematoma/ Access
Redo CEA
(n = 27)0%
4%
(minor-1)
4%#
(n=1)
4%
(n=1)
CAS
(n = 52)
2%*
(n=1)
8%**
major-1, minor-1,TIA-2
NA4%
(n=2)
** all > 24 hrs after CAS procedure
# Transient tongue deviation
* Pt treated for combined RCS & MCA stenoses – ICH (day-2)
Cerebrovascular DiseaseCerebrovascular Disease
* Developed TIA-1; Regression to <50%-1
Stenosis Category < 50% 50-74% > 75% 100%
USF - Re-do CEA
(n=27) - 38 mo FU82% 11% 7% 0%
USF - CAS
(n=51) - 24 mo FU84% 10%* 6% 0%
Months
42363024181260
Pri
ma
ry S
ten
osi
s F
ree
Pa
ten
cy
1.0
.8
.6
.4
.2
0.0
Redo-CEA
p = .25, log rank
CAS
Months
42363024181260
Pri
ma
ry S
ten
osi
s F
ree
Pa
ten
cy
1.0
.8
.6
.4
.2
0.0
Redo-CEA
p = .25, log rank
CAS
Cerebrovascular DiseaseCerebrovascular Disease
Asymptomatic
Symptomatic
Redo-CEA
InterventionRedo
PTA/CAS
Redo CEA (n=27)
100% 0% 0%7%
(n=2)
CAS
(n=51)98%
2%
(n=1)0%
8%
(n=4)
Months
4842363024181260
Re
inte
rve
ntio
n F
ree
Su
rviv
al
1.00
.80
.60
.40
.20
0.00
p = .82, log rank
Redo-CEA
CAS
Months
4842363024181260
Re
inte
rve
ntio
n F
ree
Su
rviv
al
1.00
.80
.60
.40
.20
0.00
p = .82, log rank
Redo-CEA
CAS
No patient developed ipsilateral stroke
Same patient survival @ 36 mo: 92%
Cerebrovascular DiseaseCerebrovascular Disease
SummarySummarySummarySummary Recurrent carotid stenosis can be managed by Recurrent carotid stenosis can be managed by
operative or endovascular techniques with operative or endovascular techniques with comparable periprocedural complications, and late comparable periprocedural complications, and late anatomic & neurologic outcomes.anatomic & neurologic outcomes.
The majority of RCS lesions can be treated either The majority of RCS lesions can be treated either CAS or redo-CEA – but CAS allowed the treatment CAS or redo-CEA – but CAS allowed the treatment of lesions not amenable to “open” surgical of lesions not amenable to “open” surgical repair/bypass in 1/3repair/bypass in 1/3rdrd of patients. of patients.
Duplex follow-up after both redo-CEA and CAS is Duplex follow-up after both redo-CEA and CAS is recommended to identify progressive restenosis and recommended to identify progressive restenosis and verify equivalent durability of stented carotid verify equivalent durability of stented carotid segmentssegments
Recurrent carotid stenosis can be managed by Recurrent carotid stenosis can be managed by operative or endovascular techniques with operative or endovascular techniques with comparable periprocedural complications, and late comparable periprocedural complications, and late anatomic & neurologic outcomes.anatomic & neurologic outcomes.
The majority of RCS lesions can be treated either The majority of RCS lesions can be treated either CAS or redo-CEA – but CAS allowed the treatment CAS or redo-CEA – but CAS allowed the treatment of lesions not amenable to “open” surgical of lesions not amenable to “open” surgical repair/bypass in 1/3repair/bypass in 1/3rdrd of patients. of patients.
Duplex follow-up after both redo-CEA and CAS is Duplex follow-up after both redo-CEA and CAS is recommended to identify progressive restenosis and recommended to identify progressive restenosis and verify equivalent durability of stented carotid verify equivalent durability of stented carotid segmentssegments
Cerebrovascular DiseaseCerebrovascular DiseaseSAPPHIRE TrialSAPPHIRE Trial
• Randomized, prospective study CAS (Cordis Precise stent, AngioGuard Randomized, prospective study CAS (Cordis Precise stent, AngioGuard filter) v. CEAfilter) v. CEA
• Symptomatic > 50 % stenosis, asymptomatic > 80 %Symptomatic > 50 % stenosis, asymptomatic > 80 %• 307 ‘high risk’ patients - class III/IV CHF, open cardiac sx < 6 wks, 307 ‘high risk’ patients - class III/IV CHF, open cardiac sx < 6 wks,
recent MI (< 1mo), unstable angina, need for combined CABG/carotid tx, recent MI (< 1mo), unstable angina, need for combined CABG/carotid tx, FEV < 1.0, contralat ICA occl, VC paralysis, neck XRT, recurrent FEV < 1.0, contralat ICA occl, VC paralysis, neck XRT, recurrent stenosis, high ICA lesion, prox CCA lesion, tandem stenoses, > 80 yostenosis, high ICA lesion, prox CCA lesion, tandem stenoses, > 80 yo
• Results:Results:30-day stroke, death, MI rate30-day stroke, death, MI rate CAS 5.8 % v. CEA 12.6 % CAS 5.8 % v. CEA 12.6 % (Excluding MI(Excluding MI CAS 5.5 % v. CEA 8.4% )CAS 5.5 % v. CEA 8.4% )SymptomaticSymptomatic CAS 4.2 % v. CEA 15.4 %CAS 4.2 % v. CEA 15.4 %
AsymptomaticAsymptomatic CAS 6.7 % v. CEA 11.2 %CAS 6.7 % v. CEA 11.2 %Excluding non-neurologic deathsExcluding non-neurologic deaths CAS 4.8 % v. CEA 25%CAS 4.8 % v. CEA 25%
Cerebrovascular DiseaseCerebrovascular Disease
CEA in HIGH RISK (SAPPHIRE-eligible) PatientsCEA in HIGH RISK (SAPPHIRE-eligible) Patients • Retrospective comparison consecutive CEA done in high
(n=323) and low (n=453) risk pts, 4-yr span Mayo Clinic• High risk group – positive stress test (14%), age > 80y (11%),
contralat ICA occl (9%), bad COPD (7%), high lesion (5%), recurrent stenosis (3%)
High risk Low riskP valueStroke 1.9 % 1.1 % no diffDeath 0.6 % 0 % no diffMI 3.1 % 0.9 % < .05
Stroke/Death/MI symptomatic 9.3 % 1.6 % < .005 asymptomatic 3.4 % 2.1 % no diff
Cerebrovascular DiseaseCerebrovascular DiseaseARCHeR TrialARCHeR Trial
• Prospective, single arm study CAS (Guidant Acculink Prospective, single arm study CAS (Guidant Acculink stent, Accunet filter)stent, Accunet filter)
• Symptomatic > 50 % stenosis, asymptomatic > 80 %Symptomatic > 50 % stenosis, asymptomatic > 80 %• 437 ‘high risk’ pts - 437 ‘high risk’ pts - multivessel CAD (28%), MI < 1mo, need open multivessel CAD (28%), MI < 1mo, need open
heart sx, unstable angina, EF<30%/class III/IV CHF (29%), FEV<30% heart sx, unstable angina, EF<30%/class III/IV CHF (29%), FEV<30% predicted, ESRD, bad DM, contralat ICA occl (15%), recurrent stenosis predicted, ESRD, bad DM, contralat ICA occl (15%), recurrent stenosis (32%), radical neck/XRT, high/low lesions, trach, fixed C-spine, VC (32%), radical neck/XRT, high/low lesions, trach, fixed C-spine, VC paralysis, organ transplant paralysis, organ transplant
• Successful filter use 92%Successful filter use 92%
• 30-day stroke (30-day stroke (minor 3.7%, major 1.4%), minor 3.7%, major 1.4%), death death 6.6 %6.6 %recurrent stenosis subsetrecurrent stenosis subset 0.7 % 0.7 %
30-day stroke, death, MI30-day stroke, death, MI 7.8 %7.8 %contralateral ICA occlusioncontralateral ICA occlusion 7.6 % 7.6 %ESRDESRD 29 % 29 %
Cerebrovascular DiseaseCerebrovascular DiseaseCARESS TrialCARESS Trial
• Observational Registry, CAS (Boston Scientific Observational Registry, CAS (Boston Scientific Wallstent, Medtronic GuardWire) v. CEA Wallstent, Medtronic GuardWire) v. CEA
• Symptomatic > 50 % stenosis, asymptomatic > 75 % (70%) Symptomatic > 50 % stenosis, asymptomatic > 75 % (70%)
• Patient selection based on ‘broad clinical practice’ (not high risk) Patient selection based on ‘broad clinical practice’ (not high risk)
• 2:1 CEA (n=254) to CAS (n=143) enrollment2:1 CEA (n=254) to CAS (n=143) enrollment
• 30-day stroke, all-cause mortality30-day stroke, all-cause mortality
CAS 2.1% v. CEA 2.4 %CAS 2.1% v. CEA 2.4 %
• 30-day stroke, death, MI30-day stroke, death, MI
CAS 2.1 % v. CEA 3.1 %CAS 2.1 % v. CEA 3.1 %
Cerebrovascular DiseaseCerebrovascular Disease
Other Trials:Other Trials:•SECuRITY – SECuRITY – High Risk Registry (Abbott), Procedural success at 30d 94.6%High Risk Registry (Abbott), Procedural success at 30d 94.6%
•MAVeRIC – (MAVeRIC – (MedtronicMedtronic))30d adverse event 5.2%30d adverse event 5.2%
•BEACH – BEACH – High risk trial (Boston Scintific) 30d event rate 5.4%High risk trial (Boston Scintific) 30d event rate 5.4%
•CABERNET – CABERNET – (Boston Scientific) 3.4% 30d stroke rate(Boston Scientific) 3.4% 30d stroke rate
• Downward Trend in the incidence of adverse Downward Trend in the incidence of adverse events in recent trialsevents in recent trials
Cerebrovascular DiseaseCerebrovascular DiseaseOUTCOME DETERMINANTS FOR CAS : OUTCOME DETERMINANTS FOR CAS :
UNANSWERED QUESTIONSUNANSWERED QUESTIONS • Neuro-protection devices - separating the early CAS ‘learning curve’
from more recent use of cerebral protectionwith (more recent) without (older)
Wholey et al (n=10,693) 2.3 % 5.3 %Roubin et al (n=1276) 1.8 % 6.9 %German registry (n=1353) 2.0 % 2.8 %
• Patient age Stroke/death 12 % for > 80 yo, < 5 % for younger (CREST lead-in)
More complex anatomy > 80 yo greater CAS risk ? • Plaque morphology / ‘stability’
Symptomatic (lipid-rich / soft) v. Asymptomatic (fibrous / calcific plaque) Duplex detection of optimal lesions for CAS • CAS in asymptomatic patients
CAS or CEA better than medical tx for high-risk, asymptomatic pts ?Separating high medical risk from high anatomic risk
Need for ACAS-equivalent trial (CAS v. medical tx)
Cerebrovascular DiseaseCerebrovascular Disease
Summary:Summary:
Risk of stroke from extra-cranial carotid Risk of stroke from extra-cranial carotid atherosclerosis related to stenosis severity.atherosclerosis related to stenosis severity.
Patients with carotid territory TIAs or minor stroke; & Patients with carotid territory TIAs or minor stroke; & >60% ICA stenosis benefit from surgical intervention.>60% ICA stenosis benefit from surgical intervention.
High-grade ICA stenosis (>70%) increases the risk of High-grade ICA stenosis (>70%) increases the risk of stroke in asymptomatic patients.stroke in asymptomatic patients.
Cerebrovascular DiseaseCerebrovascular Disease