Carotid Stenting: St. Mary’s Hospital 2002

1. Carotid Stenting:St. Mary’s Hospital 2002 A clinical case

2. Carotid stent team • Jeremy Chattaway • Nick Cheshire • Rodney Foale/Jamil Mayet/Iqbal Malik • Martin Clark

3. A2 M1 Ant Com Art M2 upper A1 Level of dura M2 lower Cavernous Petrous

4. 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?

5. 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

6. 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

7. 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

8. Case RH-3 • Medication • Warfarin Digoxin 125mic • Bisoprolol 2.5 Amlodipine 5 • Enalapril 15 bd Pravastatin 40 • Imdur 30 Clopidogrel 75 • Frusemide 40

9. Case RH- non-selective cerebral

10. Case RH-non-selective cerebral

11. 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

12. 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

13. Final Plan- RH • Do Both Carotids with stents? • Do one carotid only? • Risk of hyperperfusion injury • Improve hemodynamic reserve • Try second one later

14. Technique 0.035 guidewire 5F VTK catheter Sheath introducer 7F shuttle sheath

15. R

20. RH RICA day 3

21. LICA to do

22. Hall LICA Procedue

23. Hall LICA

24. Hall LICA

25. Hall LICA

26. TRAP removal

27. 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

28. 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

29. 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

30. 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?

31. 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

32. 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.

33. CAVATAS

34. CAVATAS • QOL same • Cost in lab same • Total cost greater for surgery as ITU stay • £946 • Stent • cost of PTA from £1086 to £1864

35. 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

36. 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

37. 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

38. World wide CAS

39. K. Mathias, H. Jaeger, ISET, Miami 2001

41. Asymptomatic

42. Symptomatic

43. SMH 2002-a clinical case • Patients with high risk • A research program-ICSS • Patient choice

44. Flanders study

45. 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

46. Death/ any CVA TIA MI<30d CN palsy<30d Hematoma (tx/op/long stay) >70% stenosis at FU Reintervention QOL Costs ICSS outcome events

47. 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

48. Distal protection devices

49. Distal Protection devices

50. Angioguard (Cordis) Percusurge