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Estenose c Estenose c Presentation Transcript

  • Carotid Vascular Disease: Treatment options using surgery and interventional radiology Emily Borod MS3
  • Carotid Vascular Disease
    • Stroke is 3 rd leading cause of death in US (behind heart disease and cancer)
    • Mortality from acute event is 20%
    • 50% of patients are alive after 5 years
    • 4% of survivors require long-term skilled nursing care
    • 25% of survivors will have a second neurologic event
  • Signs/symptoms of carotid vascular disease
    • TIA (Transient Ischemic Attacks): focal neurologic defects with resolution of symptoms within 24 hours
    • RIND (Reversible Ischemic Neurologic Deficit): transient neurologic defects lasting 24-72 hrs
    • Amaurosis fugax: temporary blindness in one eye, frequently described as “curtain coming down” due to microemboli in retina
    • CVA (Cerebrovascular accident): neurologic deficit with permanent brain damage
  • Evaluating carotid disease
    • Duplex Doppler ultrasonography
    • Carotid Doppler ultrasonography
    • Magnetic resonance angiography (MRA)
    • Carotid angiography (gold standard)
    • Sensitivity/specificity of noninvasive tests to predict stenoses >70% is 83-86%/89-94%
  • Duplex Doppler ultrasonography
  • MRA of carotid stenosis
  • Carotid angiography
  • Treatment options
    • Medical treatment (not as effective for more advanced disease)
    • Carotid endarterectomy (CEA)
    • Nonsurgical carotid revascularization using angioplasty and stenting
    • Treatment recommended for:
      • Asymptomatic pts with >60% stenosis
      • Symptomatic pts with >50% stenosis
  • Carotid endarterectomy
    • Performed through neck incision, usually along sternocleidomastoid muscle
    • Proximal and distal control of artery is obtained
    • While patient is heparinized, internal and external carotid arteries are clamped
    • Longitudinal arteriotomy is performed, carotid plaque is removed, and vessel is closed over a patch
  • Complications of carotid endarterectomy (perioperative mortality <0.5-3.0%, related level of expertise of surgeons)
    • Cardiac events
    • Postoperative stroke
    • Hyperperfusion syndrome
    • Nerve injury
    • Bleeding
    • Infection
    • Parotitis
    • Re-stenosis
  • Postoperative cardiac events
    • Appropriate cardiac work-up is essential
    • Because these patients have atherosclerotic disease in the carotids, it must be assumed that they have atherosclerotic disease elsewhere
    • Exercise stress testing, dobutamine echocardiography, dipyridamole imaging, or coronary catherization should be used
  • Postoperative stroke
    • Factors that contribute to postoperative stroke:
      • Plaque emboli
      • Platelet aggregates
      • Improper flushing
      • Poor cerebral protection
      • Relative hypotension
  • Hyperperfusion syndrome
    • Cerebral hyperperfusion is the leading cause of intracerebral hemorrhage and seizures during the first two weeks following CEA
    • Causes changes in low-flow carotid vascular bed
    • Small vessels compensate by dilating, then cannot re-constrict properly and therefore cannot protect vascular bed
  • Nerve injury
    • Nerves at risk for injury during CEA include:
      • Vagus nerve
      • Recurrent laryngeal nerve
      • Facial nerve
      • Glossopharyngeal nerve
      • Hypoglossal nerve
      • Branches of trigeminal nerve
  • Re-stenosis
    • Re-stenosis following CEA occurs in 20% of patients overall, and 2.6-10% at 5 years
    • Re-stenosis within 6 months is more common when smooth muscle cells are abundant in lesion and is less common when lesions are rich in lymphocytes and macrophages
    • Late re-stenosis results from progression of atherosclerotic disease
  • Carotid endarterectomy
  • Predictors of mortality following CEA
    • Increased age
    • Male sex (relative risk 1.58)
    • Diabetes (RR 1.48)
    • Systemic hypertension (RR 1.31)
    • Smoking (RR 1.13)
  • Predictors of recurrence following CEA
    • Elevated cholesterol
    • Systemic hypertension (RR 1.42)
    • Smoking (RR 1.47)
  • Nonsurgical carotid revascularization
    • Percutaneous catheterization techniques have led to carotid angioplasty and stent placement
    • Less invasive (performed with local anesthesia and sedation)
    • Less likely to precipitate cardiac events
    • Technique can also be used to repair stenosis that is more cephalad
  • Technique used in nonsurgical carotid repair
    • Catheter with umbrella tip is inserted in stenotic carotid via femoral artery
    • Balloon is inflated to dilate artery
    • Stent is placed in artery to maintain patency
    • Filters are used to capture embolic particles
  • Examples of stents used in carotid revascularization
  • Filters used in carotid repair
  • Pre- and post-stenting angiography
  • Risks of nonsurgical vascular repair
    • Plaques may be dislodged during procedure leading to neurologic events
    • Re-stenosis is common in long term follow-up (15%) and may be difficult to treat surgically
    • Dissection has been shown to occur in 5% of patients following stenting
    • More studies comparing CEA to nonsurgical repair must be completed
  • CEA vs stenting
    • Several studies have been carried out or are in progress to compare CEA and repair of carotid artery disease using interventional radiology
    • Because of the potentially significant and lasting damage from a stroke and the relative success of CEA, studies comparing the two treatment options have been somewhat slow to be carried out
    • Most of the early studies compare the two techniques in specific patient groups (i.e. elderly patients or poor surgical candidates)
  • WALLSTENT trial
    • 219 patients with symptomatic stenosis
    • Carotid arteries were 60-90% occluded
    • Patients were randomly assigned to receive CEA or angioplasty and stenting ( without protective filter device)
    • 1-yr follow-up showed significantly higher rate of post-procedure stroke with angioplasty and stenting group compared to CEA group (12.2 vs 3.6%)
  • SAPPHIRE study
    • CEA vs carotid stenting with protective filter device
    • 334 patients with concurrent conditions that made them poor surgical candidates
    • Symptomatic carotid stenosis of  50% or asymptomatic stenosis of  80%
    • Primary end-point: major cardiovascular event within one year (death, stroke, MI)
  • Results of SAPPHIRE study
    • Major cardiovascular events within one year were more common in CEA group than in angioplasty and stenting group (20.1% compared to 12.2%)
    • Carotid revascularization was repeated within one year in fewer patients with stents than in patients who underwent CEA (0.6% and 4.3%, p=.04)
  • Stenting vs CEA in elderly patients
    • Retrospective study of pts  75 years old who had been treated for carotid stenosis
    • 53 pts who had undergone stenting between June 2001 and April 2004 were compared to 110 pts who had undergone CEA between January 1997 and December 2001
    • Primary outcome was MI or major, minor, or fatal stroke within one month of treatment
  • Results of CEA vs stenting in elderly patients
    • Incidence of major or minor stroke within 30 days of treatment was significantly higher in stenting than in CEA group (11.3% to 1.8%, P<0.05)
    • Incidence of major stroke within 30 days was similar in the two groups, but incidence of minor strokes was higher in stenting group (7.5% vs 0%, P<0.05)
    • Protective embolic filter devices were used in this trial
  • CAVATAS trial
    • 504 pts with carotid stenosis were randomly assigned to CEA or angioplasty and stenting
    • Results showed similar major risks and effectiveness of the two treatment options
    • Outcomes following surgery were worse than outcomes reported in major trials evaluating carotid surgery, supporting the fact that there is a great deal of variability in outcome depending on surgeon expertise
  • Conclusion
    • Carotid vascular disease is prevalent in the US and results in significant mortality and morbidity when untreated
    • Results of trials comparing the invasive treatment options are ongoing and have shown somewhat conflicting results
    • Studies support the use of angioplasty and stenting in certain patient populations
  • Conclusion
    • Patients with carotid stenosis who are likely to benefit more from carotid angioplasty and stenting than from CEA include pts with significant comorbidities that make them poor surgical candidates
    • Elderly pts may be at higher risk of having a minor stroke within 30 days following stenting than CEA
    • The use of protective embolic filters is important in the outcome following angioplasty and stenting
  • Conclusion
    • Stenting is a promising option for treating carotid stenosis in patients who are high-risk surgical candidates
    • More studies comparing the revascularization procedures are necessary before treatment recommendations can be refined
    • Attention to long-term results of stenting should also be compared to long-term CEA results
  • References
    • Alhaddad, I.A.; Carotid Artery Surgery vs. Stent: A Cardiovascular Perspective; Catheterization and Cardiovascular Interventions ; 63:377-384 (2004).
    • Brott, T.G., et al; Carotid Revascularization for Prevention of Stroke: Carotid Endarterectomy and Carotid Artery Stenting; Mayo Clinic Proceedings , 79(9), 1197-1208 (2004).
    • Eskandari, M.K., et al; Does Carotid Stenting Measure Up to Endarterectomy? A Vascular Surgeon’s Experience; Archives of Surgery , Vol.139, pp. 734-738 (2004).
    • Greelish, J.P., et al; Nonsurgical carotid revascularization; UpToDate ,
    • Greelish, J.P., et al; Carotid endarterectomy: Preoperative evaluation, surgical technique, and complications; UpToDate ,
  • References
    • Phatouros, C.C., et al; Carotid Artery Stent Placement for Atherosclerotic Disease: Rationale, Technique, and Current Status; Radiology ; Oct 2000.
    • Kastrup, A., et al; Comparison of angioplasty and stenting with cerebral protection versus endarterectomy for treatment of internal carotid artery stenosis in elderly patients; Journal of Vascular Surgery , Nov. 2004.
    • Kirsch, E.C., et al; Carotid Arterial Stent Placement: Results and Follow-up in 53 Patients; Radiology ; Sept. 2001.
    • Yadav, J.S., et al; Protected Carotid-Artery Stenting versus Endarterectomy in High-Risk Patients; The New England Journal of Medicine , 351:15 (2004).