Carotid stenosis (cqc)

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Carotid stenosis (cqc)

  1. 1. CQC Tom Oryszczak 10/21/08 Loyola University Medical Center
  2. 2. Our Patient <ul><li>63 y/o M being treated for pneumonia </li></ul><ul><li>Discovered to have severe AS on echo (Ao gradient = 46mmHg) </li></ul><ul><li>No SOB, syncope, chest pain </li></ul><ul><li>Planned aortic valve replacement </li></ul><ul><li>Work up for AVR discovers 50-59% stenosis of Lt carotid artery </li></ul><ul><li>No prior TIA symptoms, no focal deficits </li></ul>
  3. 3. What is the evidence to support carotid endarterectomy in asymptomatic patients? <ul><li>1993 – VA cooperative study group </li></ul><ul><li>1995 – ACAS trial </li></ul><ul><li>2004 – ACST trial </li></ul>
  4. 4. VA cooperative study group <ul><li>444 asymptomatic men with 50-99% stenosis </li></ul><ul><li>ASA vs ASA + CEA </li></ul><ul><li>Endpoints: </li></ul><ul><ul><li>TIA </li></ul></ul><ul><ul><li>transient monocular blindness </li></ul></ul><ul><ul><li>stroke </li></ul></ul><ul><li>48 month follow up </li></ul><ul><li>8% vs 20.6% (RR=0.38) </li></ul>
  5. 5. ACAS <ul><li>1662 asymptomatic patients with 60-99% stenosis </li></ul><ul><li>ASA vs ASA + CEA </li></ul><ul><li>End points </li></ul><ul><ul><li>infarction in artery distribution </li></ul></ul><ul><ul><li>perioperative stroke or death </li></ul></ul><ul><li>Study halted at 2.7 years </li></ul><ul><li>5.1% vs 11% (RR=0.53) </li></ul><ul><li>Risk reduction unequal in women and men (17% vs 66%) </li></ul>
  6. 6. ACST <ul><li>3120 asymptomatic patients with 60-99% stenosis </li></ul><ul><li>immediate CEA vs delayed CEA </li></ul><ul><li>End points: </li></ul><ul><ul><li>perioperative mortality and stroke </li></ul></ul><ul><ul><li>non-perioperative stroke </li></ul></ul><ul><li>3.6 years mean follow up </li></ul>
  7. 7. ACST trial <ul><li>3.1% incidence in 30-day perioperative events </li></ul><ul><li>Women received only half the benefit of male patients (4.0 vs 8.1% risk reduction) </li></ul><ul><li>Data for elderly (>75) is unclear </li></ul><ul><li>Early CEA beneficial for reduction of ipsilateral and contralateral stroke </li></ul>Stroke or perioperative mortality
  8. 8. Pitfalls in trial data <ul><li>Does not reflect advances in medical management </li></ul><ul><li>Poor correlation with symptomatic carotid artery stenosis trials </li></ul><ul><ul><li>Does stenotic lesion account for future strokes? </li></ul></ul><ul><ul><li>No correlation with degree of stenosis and event rate </li></ul></ul><ul><li>Can you just wait for TIA symptoms? </li></ul>
  9. 9. Guidelines <ul><li>American Academy of Neurology Recommendations, 2005 </li></ul><ul><li>For asymptomatic patients with 60 to 99% stenosis, the benefit/risk ratio is smaller compared to symptomatic patients and individual decisions must be made. Endarterectomy can reduce the future stroke rate if the perioperative stroke/death rate is kept low (3%). </li></ul><ul><li>(Level A) </li></ul><ul><li>American Heart Association Recommendations, 2001 </li></ul><ul><li>Endarterectomy may be considered in patients with high-grade asymptomatic carotid stenosis performed by a surgeon with less than 3% morbidity/mortality rate. (Level of Evidence I, Grade A) </li></ul>
  10. 10. Factors to consider <ul><li>Eligibility as a surgical candidate </li></ul><ul><ul><li>age, sex, comorbid conditions </li></ul></ul><ul><li>Estimated life-span </li></ul><ul><li>Prior ischemic events </li></ul><ul><li>Contralateral occlusion </li></ul><ul><li>Surgeon’s perioperative complication rate </li></ul><ul><li>Advances in non-surgical management </li></ul>
  11. 11. Closing Arguments <ul><li>Annual risk of stroke 3.2% for patients with 60-99% stenosis </li></ul><ul><li>NNT = 33 based on strict interpretation of data </li></ul><ul><li>SMART trial  stenosis is independent risk factor for all vascular events </li></ul><ul><li>MACE trial  ASA better than surgery </li></ul><ul><li>TNT trial  intensive statin therapy reduced CVA risk by 22% </li></ul>
  12. 12. References <ul><li>Hobson, RW 2d, Weiss, DG, Fields, WS, et al. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. The Veterans Affairs Cooperative Study Group. N Engl J Med 1993; 328:221. </li></ul><ul><li>Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995; 273:1421. </li></ul><ul><li>Halliday, A, Mansfield, A, Marro, J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004; 363:1491. </li></ul><ul><li>Results of a randomized controlled trial of carotid endarterectomy for asymptomatic carotid stenosis. Mayo Asymptomatic Carotid Endarterectomy Study Group. Mayo Clin Proc 1992; 67:513. </li></ul><ul><li>Chaturvedi , S, Bruno, A, Feasby , T, et al. Carotid endarterectomy--an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005; 65:794. </li></ul><ul><li>Goldstein, LB, Adams, R, Becker, K, et al. Primary prevention of ischemic stroke: A statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke 2001; 32:280. </li></ul><ul><li>Barnett, HJM, Taylor, DW, Eliasziw , M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998; 339:1415. </li></ul><ul><li>LaRosa J.C., Grundy S.M., Waters D.D., Shear C., Barter P., Fruchart J.C., Gotto A.M., Greten H., Kastelein J.J., Shepherd J., Wenger N.K.:  Treating to New Targets (TNT) Investigators.  Intensive lipid lowering with atorvastatin in patients with stable coronary disease N Engl J Med  352. 1425-1435.2005;  </li></ul>

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