Estenose c


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Estenose c

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