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Carotid stenosis (cqc)

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  • 1. CQC Tom Oryszczak 10/21/08 Loyola University Medical Center
  • 2. Our Patient
    • 63 y/o M being treated for pneumonia
    • Discovered to have severe AS on echo (Ao gradient = 46mmHg)
    • No SOB, syncope, chest pain
    • Planned aortic valve replacement
    • Work up for AVR discovers 50-59% stenosis of Lt carotid artery
    • No prior TIA symptoms, no focal deficits
  • 3. What is the evidence to support carotid endarterectomy in asymptomatic patients?
    • 1993 – VA cooperative study group
    • 1995 – ACAS trial
    • 2004 – ACST trial
  • 4. VA cooperative study group
    • 444 asymptomatic men with 50-99% stenosis
    • ASA vs ASA + CEA
    • Endpoints:
      • TIA
      • transient monocular blindness
      • stroke
    • 48 month follow up
    • 8% vs 20.6% (RR=0.38)
  • 5. ACAS
    • 1662 asymptomatic patients with 60-99% stenosis
    • ASA vs ASA + CEA
    • End points
      • infarction in artery distribution
      • perioperative stroke or death
    • Study halted at 2.7 years
    • 5.1% vs 11% (RR=0.53)
    • Risk reduction unequal in women and men (17% vs 66%)
  • 6. ACST
    • 3120 asymptomatic patients with 60-99% stenosis
    • immediate CEA vs delayed CEA
    • End points:
      • perioperative mortality and stroke
      • non-perioperative stroke
    • 3.6 years mean follow up
  • 7. ACST trial
    • 3.1% incidence in 30-day perioperative events
    • Women received only half the benefit of male patients (4.0 vs 8.1% risk reduction)
    • Data for elderly (>75) is unclear
    • Early CEA beneficial for reduction of ipsilateral and contralateral stroke
    Stroke or perioperative mortality
  • 8. Pitfalls in trial data
    • Does not reflect advances in medical management
    • Poor correlation with symptomatic carotid artery stenosis trials
      • Does stenotic lesion account for future strokes?
      • No correlation with degree of stenosis and event rate
    • Can you just wait for TIA symptoms?
  • 9. Guidelines
    • American Academy of Neurology Recommendations, 2005
    • 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%).
    • (Level A)
    • American Heart Association Recommendations, 2001
    • 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)
  • 10. Factors to consider
    • Eligibility as a surgical candidate
      • age, sex, comorbid conditions
    • Estimated life-span
    • Prior ischemic events
    • Contralateral occlusion
    • Surgeon’s perioperative complication rate
    • Advances in non-surgical management
  • 11. Closing Arguments
    • Annual risk of stroke 3.2% for patients with 60-99% stenosis
    • NNT = 33 based on strict interpretation of data
    • SMART trial  stenosis is independent risk factor for all vascular events
    • MACE trial  ASA better than surgery
    • TNT trial  intensive statin therapy reduced CVA risk by 22%
  • 12. References
    • 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.
    • Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995; 273:1421.
    • 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.
    • 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.
    • 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.
    • 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.
    • 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.
    • 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; 

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