Upload
others
View
6
Download
0
Embed Size (px)
Citation preview
11/18/2014
1
Asymptomatic Carotid StenosisAsymptomatic Carotid Stenosis
Munier Nazzal, MD, FRCS, FACS, FACCWSProfessor, General Surgery Program Director
Chief Division, Vascular &Endovascular SurgeryUniversity of Toledo, OH, USA
Stroke , 2014, Toledo, Ohio
Dislcosure Investigator in SAPPHIRE
Speaker for Medtronic, argon
PI in CREST, and Oxford.
Case 65 year , male patient.
DM, HTN, CAD
Bilateral carotid stenosis : left (60%) symptomatic : CEA. Right side has 65% asymptomatic : Conservative therapy
Discharge home after surgery and followed up in the clinic for three months/ During this time he was always asking to do CEA for the right side: convinced not to.
2 months later admitted with right hemispheric stroke and then rehab
11/18/2014
2
Prevalence of ACAS
Carotid disease : Facts 87% of all CEA are in asymptomatic patients.
Carotid stenosis is a a marker for CVS and for cardiac death.
Women do not benefit as much as men from CEA or CAS.
Both CEA and CAS are not as safe in older patients.
More than 60% of the cases or CEA are done in patients older than 70 years.
11/18/2014
3
Asymptomatic CAS studies
Schneider etal., 2010
Randomized Trials
Asymptomatic Carotid StenosisAsymptomatic Carotid Stenosis
5 Year Risk of Cerebral Events
ACAS ACST
BMT CEA ARR BMT CEA ARR
Ipsilat Stroke 11.0% 5.1% 5.9% 5.1% 4.4% 1.1%
Any Stroke 17.5% 12.4% 5.1% 11.8% 6.4% 5.4%
Major Stroke 9.1% 6.4% 2.7% 6.1% 3.5% 2.6%
Naylor A R et alEJVES 2009.01.026 (epub 4/09)
Cutlip et al, circulation 2012
11/18/2014
4
Asymptomatic Carotid DiseaseAsymptomatic Carotid Disease
procedural risk - 2.3%
Prevent almost 60 stroke (ipsilateral ) in 1000 patients compared to Medical therapy done in the
80’s and 90’s
procedural risk - 2.3%
Prevent almost 60 stroke (ipsilateral ) in 1000 patients compared to Medical therapy done in the
80’s and 90’s
ACASJAMA 1995; 273:1421
Asymptomatic Carotid Disease
Asymptomatic Carotid Disease
…To operate on all patients with more than 60% stenosis will prevent about 5% of all strokes according to the literature
…To operate on all patients with more than 60% stenosis will prevent about 5% of all strokes according to the literature
Naylor A RSurgeon 2007; 5:23
Hankey G JMed J Aust 1995; 163:197
Stroke 2013
11/18/2014
5
293 (6.8%) patients with ACAS 50% to 99%, of whom 193 had 70% to 99% stenosis. mean follow‐up was 6.2 and 6.0 years, respectively.
Any territory annual ischemic stroke risk was 0.4% in 50% to 99% ACAS and 0.5% per year for 70% to 99% ACAS patients.
The risk of ischemic stroke was not significantly increased in patients with ACAS 70% to 99% 0.5–4.2 and hazard ratio, 1.7; 95% confidence interval, 0.5–5.6).
Challenges
Medical care ???? Best medical therapy not well defined.
Statins
Antiplatelets.
Hypertension control
Smoking cessation
11/18/2014
6
Asymptomatic Not all asymptomatic behave the same.
Age : is a factor
Comorbidities
Asymptomatic Carotid Disease
The best results for asymptomatic carotid stenosis came from the following two studies
Asymptomatic Carotid Atherosclerosis Study (ACAS)
Asymptomatic Carotid Surgery Trial (ACST)
Most feared:Stroke
Most frequent : Myocardial infarction
death
only one third to one half of these strokes were ischemic and ipsilateral and could be attributed to the carotid stenosis, others have other reasons
Forty‐five percent of strokes in patients with asymptomatic stenosis of 60 to 99 percent are attributable to lacunes or cardioembolism
Inzitari et al, NEJM 2000
11/18/2014
7
Carotid Endarterectomy in the USA
Procedural Risk (Stroke/Death) ‐ 3.8%
“? Real‐World Results”
• 44 ipsilateral strokes prevented per 1000 procedures at 5 years
• 5,411 strokes prevented from 122,986 procedures
• $428,510 per stroke prevented
Procedural Risk (Stroke/Death) ‐ 3.8%
“? Real‐World Results”
• 44 ipsilateral strokes prevented per 1000 procedures at 5 years
• 5,411 strokes prevented from 122,986 procedures
• $428,510 per stroke prevented
Kresowik T FJ Vasc Surg 2004; 39:372
1. Calhoun HMLancet 2004; 364: 685
2. MRC/BHF HPS Investigators,Lancet 2002; 360:7
1. Calhoun HMLancet 2004; 364: 685
2. MRC/BHF HPS Investigators,Lancet 2002; 360:7
25%25%5.0 yrs 5.0 yrs High Risk2High Risk2
46%46%3.9 yrs 3.9 yrs Diabetics1Diabetics1
RRRRRRF/UF/UPatientsPatients
Statins vs. Placebo
Statins and Risk of StrokeStatins and Risk of Stroke
Results at 4.9 yearsResults at 4.9 years
SPARCL InvestigatorsNEJM 2006;355:549
EndpointEndpoint RRRRRR P‐valueP‐value
• 4731 stroke / TIA patients
• Randomized: atorvastatin 80mg vs. placebo
• 4731 stroke / TIA patients
• Randomized: atorvastatin 80mg vs. placebo
Stroke (any)Stroke (any)
Stroke/TIAStroke/TIA
Any CV eventAny CV event
Major CV eventMajor CV event
16%16%
35%35%
26%26%
23%23%
.03.03
<.001<.001
<.001<.001
<.001<.001
Risk Reduction with StatinSPARCL TrialSPARCL Trial
SPARCL study
11/18/2014
8
• Prospective
• 2684 consecutive patients– Clinical manifestations of arterial disease, or– Type II diabetes
• No history of cerebral ischemia
• Carotid duplex
• 221 (8%) ≥50% carotid stenosis
• Follow‐up to 5 years (mean 3.6 years)
• Evaluated for ischemic events
• Prospective
• 2684 consecutive patients– Clinical manifestations of arterial disease, or– Type II diabetes
• No history of cerebral ischemia
• Carotid duplex
• 221 (8%) ≥50% carotid stenosis
• Follow‐up to 5 years (mean 3.6 years)
• Evaluated for ischemic events
Second Manifestation of ARTerial DiseaseSecond Manifestation of ARTerial Disease
The SMART Study(2007)
The SMART Study(2007)
Bertine M B et alStroke 2007; 38:1470
Annual risk of “ipsilateral” or “any” stroke from
50 ‐ 99% stenosis was <1%
Annual risk of “ipsilateral” or “any” stroke from
50 ‐ 99% stenosis was <1%
SMART Study
Asymptomatic Carotid DiseaseAsymptomatic Carotid Disease
Goessens B M B et alStroke 2007; 38:1470
Annual risk of “ipsilateral” or “any” stroke from
50 ‐ 99% stenosis was <1%
Can Medical Therapy Control ACAS
11/18/2014
9
Medically managed patients with ASCAS develop INS early, especially in patients with VSS. Medical therapy with aspirin and statins failed to control ASCAS, thus validating the role of CEA in these patients as promulgated in multiple current treatment guidelines.
JVS 2014
11/18/2014
10
JVS, 2010
Factors evaluated:Age, gender, BMI, SBP, DBP, smokingMedications: antiplatelets, HTN, lipids.HTN, CAD, DM, stroke/TIA of other carotid side.ECG of a‐fib, MI, ischemic LVHFibrinogen, lipids levels, S‐creat, Hct,
11/18/2014
11
In press, JVS
11/18/2014
12
Conclusions of the Study Progressive asymptomatic carotid stenosis identified a
subgroup with about twice the risk of ipsilateral stroke compared with those without progression.
The clinical value of screening for progression simply for selecting patients for carotid procedures is limited because of the low frequency of progression and its relatively low associated stroke rate.
The cost effectiveness of screening for change in stenosis severity to better direct current optimal medical treatment needs testing.
Kakkos et al, JVS 2014
Characteristic Asymptomatic (n = 1181)
Symptomatic (n = 1321) P
Age, years (mean ± SD) 69.3 ± 8.1 68.8 ± 9.5 <0.17
Male, % 65.6 64.7 0.64
Hypertension, % 88.0 84.0 0.004
Diabetes, % 33.2 28.1 0.006
Dyslipidemia, % 90.4 79.0 <0.0001
Current smoker, % 24.1 28.2 0.02
Stroke. 2011;42:875-880
11/18/2014
13
4 year event rate for stroke, MI, and death (%)
Stroke. 2011;42:875-880
Lancet. 2014;383:333-341
11/18/2014
14
High Grade Stenosis
Look for ContraindicationsFor Surgery
Randomize
Surgeon OR Interventionist
Look for ContraindicationsFor Stenting
Decide Type of Revasc best for patient
• Preoperative• Aspirin + statin load (CEA) and• Dual antiplatelets + statin load (CAS)
• Patients in both trials will take aspirin 325 mg/day for the entire follow-up period
• CAS patients will also take clopidogrel per protocol
• Primary risk factor control managed by the study physician. Focused on:• Target systolic blood pressure <140 mmHg• Target LDL <70 mg/dl
• Is the change of cognitive function from
baseline to 48 months no worse among those
in the MEDICAL cohort compared to the
CEA/CAS cohorts? (Cognitive function may be a
surrogate for TIA and/or asymptomatic brain injury).
• Computer-aided telephonic assessment by
team at University of Alabama at Birmingham.
11/18/2014
15
Asymptomatic carotid stenosis
Degree of stenosis
Age
Condition of Patients
Experience of the Operator