510 likes | 886 Views
Carotid Stenting: St. Mary’s Hospital 2002. A clinical case. Carotid stent team. Jeremy Chattaway Nick Cheshire Rodney Foale/Jamil Mayet/Iqbal Malik Martin Clark. A2. M1. Ant Com Art. M2 upper. A1. Level of dura. M2 lower. Cavernous. Petrous. Background. Then:
E N D
Carotid Stenting:St. Mary’s Hospital 2002 A clinical case
Carotid stent team • Jeremy Chattaway • Nick Cheshire • Rodney Foale/Jamil Mayet/Iqbal Malik • Martin Clark
A2 M1 Ant Com Art M2 upper A1 Level of dura M2 lower Cavernous Petrous
Background • Then: • “PTCA is barbaric and without evidence as a treatment for CAD” • Now: • Coronary stenting accepted as standard therapy for CAD • Could the same happen for carotid stenting?
Pre-requisites for success • Prove surgery is better than tablets • Prove percutaneous approach is almost as good as surgery • Add stents/adjunctive therapy to make percutaneous equivalent to surgery
Age 63 male PMH Severe AR LAD stenosis Poor LV Risk Factors HT Lipids DM PVD Ex- Smoking Cerebrovascular Hx “TIA” 15 yrs ago Asymptomatic now Case RH-1 • Cardiac Hx increasing dyspnoea no angina
Investigations ECG Lat ST sag Echo LV7/8cm Mod severe AR Creatinine 152 K 3.8 Hb 15.0 INR 1.2 CVD Investigations Duplex MRA Arch angio Case RH-2
Case RH-3 • Medication • Warfarin Digoxin 125mic • Bisoprolol 2.5 Amlodipine 5 • Enalapril 15 bd Pravastatin 40 • Imdur 30 Clopidogrel 75 • Frusemide 40
Plan of action-RH • Aim • Reduce CVA risk prior to AVR and grafts • Rationale • Discussed twice at neurovascular meeting • Risks of CEA high-not a suitable candidate • Discussed twice at Joint cardiology/surgery meeting • Needs AVR otherwise cardiac lifespan limited • Discussed by CAS team
Risk of AVR/CABG >3000 pts CVA risk Stenosis <50% 1.6% Stenosis 50-99% 3.8% Occlusion 6.5% Occ+stenosis 25% CEA plus CABG/AVR CEA first Cardiac risk very high Cardiac/CEA togather Shorter stay 10 days Higher CVA/death risk? 9.5% vs 5.7% 30d risk Cardiac first Asymptomatic >70% stenosis 1%/yr CVA Evidence based medicine
Final Plan- RH • Do Both Carotids with stents? • Do one carotid only? • Risk of hyperperfusion injury • Improve hemodynamic reserve • Try second one later
Technique 0.035 guidewire 5F VTK catheter Sheath introducer 7F shuttle sheath
RH • Rx with aspirin + clopidogrel for 4 weeks • Returned for AVR 4 weeks later • LIMA graft to LAD • Bileaflet AVR • Remarkable recovery • Plan for home day 7 • Returned to ITU day 7 • chest infection • Home day 12
Pre-requisites for success • Prove surgery is better than tablets • Prove percutaneous approach is almost as good as surgery • Add stents/adjunctive therapy to make percutaneous equivalent to surgery
Background • Stroke in the population • 12% of all deaths in UK are due to CVA • 1 million CVA in Europe/year • Carotid stenosis is major cause of CVA • Recent symptoms-28% 2-year risk CVA • Incidence of carotid stenosis >80% 0.3-2.4% of population
CEA tricky Restenosis Not C2-C7 Hostile neck RT Surgery Scars High risk Medical Morbidity Neuro Morbidity RLN palsy contralat CAS Minimally Invasive No scar No GA Easy Equivalent Treatment of occlusion post CEA Why have a stent program?
Prove surgery is better than tablets • Eastcott/ Debakey 1953 CEA • NASCET (659) • >70% stenosis • 2-yr fu CVA 9% vs 26% on medical Rx • ECST (3024) • >60% stenosis • 3-yr fu CVA 14.9% vs 26.5% on medical Rx • ACAS • >60% stenosis • 5-yr fu CVA 5.1% vs 11% on medical Rx
Prove percutaneous approach is almost as good as surgery • Carotid and vertebral artery angioplasty study • Randomisation 1992-1997 • 560 pts • 504 PTA vs surgery • 86% stenosis • Only 55 stents used • One CVA at time of stent.
CAVATAS • QOL same • Cost in lab same • Total cost greater for surgery as ITU stay • £946 • Stent • cost of PTA from £1086 to £1864
Carotid Stenting • At first… • 5 out of 7 had CVA with stent (RCT 1998) • 219 patients- death<1 year/CVA 12.1% stent vs. 3.6% CEA (p = 0.022). (RCT 2001) • Randomised Trials
Stent vs surgery • ICSS • SPACE- Stent-protected Percutanous Angioplasty-Carotid Endarterectomy trial • EVA-3S- Endarterectomy versus angioplasty in patients with severe symptomatic carotid stenosis study • CREST- Carotid Revascularisation Endarterectomy vs stenting trial • SAPPHIRE-Stenting and Angioplasty with protection in Patients with High Risk for Endarterectomy
Randomized Studies CAVATAS completed(only 30% stent use) CREST (NIH/NHLBI)(U.S., 2500 pts., low risk) SAPPHIRE(U.S., 600-900 pts., high risk population CAVATAS 2 (society initiated)(worldwide 2000 pts.) SPACE (society initiated)(Germany, 1900 pts.) High Risk Registriesincluding 2400 patients ARCHeR Maverick Beach Mednova Cabernet Trial Update
SMH 2002-a clinical case • Patients with high risk • A research program-ICSS • Patient choice
Inclusion >40 >70% stenosis Extracranial IC or bifurcation lesion Excusion CVA with no recovery Can’t stent Tortuous Thrombus Common carotid stenosis Pseudo-occlusion Can’t op ICSS entry criteria
Death/ any CVA TIA MI<30d CN palsy<30d Hematoma (tx/op/long stay) >70% stenosis at FU Reintervention QOL Costs ICSS outcome events
Conclusion • The carotid is 25 years behind the coronary • It is catching up fast. • Different vessel and vascular bed (cf diabetes) • The multidisciplinary team • SMH at the lead
Angioguard (Cordis) Percusurge