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Cerebrovascular Cerebrovascular Disease Disease Murray Shames, M.D. Murray Shames, M.D. Assistant Professor of Surgery and Assistant Professor of Surgery and Radiology Radiology Division of Vascular Division of Vascular and Endovascular and Endovascular Surgery Surgery

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Page 1: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 2: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular 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)

Page 3: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 4: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 5: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 6: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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:

Page 7: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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)

Page 8: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

Carotid Dissection:Carotid Dissection:

Traumatic Traumatic disruption of disruption of intimaintima Compression Compression of true lumenof true lumen

Page 9: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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.

Page 10: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 11: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

Atherosclerosis:Atherosclerosis:

Flow reducingFlow reducing EmbolicEmbolic

ClotClotPlateletsPlateletsCholesterol debrisCholesterol debris

ThrombosisThrombosis

Page 12: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 13: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

Presentation:Presentation:

AsymptomaticAsymptomatic

Transient Ischemic AttacksTransient Ischemic Attacks

Cerebral InfarctionCerebral Infarction

Page 14: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 15: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

Surveillance:Surveillance:

Duplex scan q 6-Duplex scan q 6-12 months12 months

Page 16: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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:

Page 17: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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:

Page 18: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 19: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 20: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 21: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 22: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 23: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

v

The Doppler

Principle

skinfo

f

Doppler Measurement of Blood Flow Velocity:Doppler Measurement of Blood Flow Velocity:

Sample Volume

VelocityProfile

Page 24: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

Duplex Ultrasound:Duplex Ultrasound:

Page 25: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 26: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

Contrast Angiography:Contrast Angiography:

High grade ICA stenosis

Page 27: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

High Resolution B-mode Imaging:High Resolution B-mode Imaging:

proximalproximal

Page 28: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

Magnetic Resonance Angiography:Magnetic Resonance Angiography:

Page 29: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

Magnetic Resonance Angiography:Magnetic Resonance Angiography:

Page 30: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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.

Page 31: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 32: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 33: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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:

Page 34: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 35: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 36: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

Carotid Endarterectomy:Carotid Endarterectomy:

Considerations:Considerations: AnesthesiaAnesthesia

GeneralGeneral RegionalRegional

ShuntShunt PatchPatch

Page 37: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

Carotid Endarterectomy:Carotid Endarterectomy:

Page 38: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

Carotid Endarterectomy:Carotid Endarterectomy:

Page 39: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

Carotid Endarterectomy:Carotid Endarterectomy:

Page 40: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

Page 41: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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%

Page 42: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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)

Page 43: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease

Carotid Artery StentingCarotid Artery Stenting

Page 44: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 45: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 46: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 47: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 48: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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)

Page 49: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 50: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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%

Page 51: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 52: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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%

Page 53: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 54: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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 %

Page 55: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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 %

Page 56: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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

Page 57: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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)

Page 58: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

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.

Page 59: Cerebrovascular Disease Murray Shames, M.D. Assistant Professor of Surgery and Radiology Division of Vascular and Endovascular Surgery

Cerebrovascular DiseaseCerebrovascular Disease