indications for cas vs surgical_medical marianne brodmann division of angiology graz
TRANSCRIPT
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!