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Carotid Plaque – Keep it or remove it ?

Carotid Plaque – Keep it or remove it ?. Dr Karen Tung Lok Man PYNEH. Epidemiology in HK. Stroke is major cause of morbidity and mortality around the world 4th cause of mortality in HK resulting in >3000 deaths every year. Department of Health 2011. Stroke.

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Carotid Plaque – Keep it or remove it ?

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  1. Carotid Plaque – Keep it or remove it ? Dr Karen Tung Lok Man PYNEH

  2. Epidemiology in HK • Stroke is major cause of morbidity and mortality around the world • 4th cause of mortality in HK resulting in >3000 deaths every year Department of Health 2011

  3. Stroke • 80 % of strokes : ischaemic in orgin • 20 – 25 % of ischaemic stroke : carotid stenosis • Risk of stroke correlates with severity of carotid stenosis Prevention

  4. Treatment options Medical therapy Carotid artery stenting Carotid endarterectomy

  5. Carotid Endarterectomy (CEA) • First described in 1953 • Widely used invasive treatment for significant carotid stenosis • Efficacy was established by 4 RCTs in late 1980s and early 1990s

  6. CEA superior to medical therapy Symptomatic carotid stenosis • North American Symptomatic Carotid Endarterectomy Trial (NASCET) • Carotid stenosis 70 – 99% : 2 yrs stroke reduced from 26% to 9% (p<0.001) • Carotid stenosis 50 – 69% : 2 yrs stroke reduced from 22.2% to 15.7% (p<0.045) • Carotid stenosis <50% : no benefit • European Carotid Surgery Trial (ECST) JM Henry N Eng Jounral of Medicine 1998 PM Rothwell Lancet 1998

  7. CEA superior to medical therapy Asymptomatic carotid stenosis • Asymptomatic Carotid Surgery Trial (ACST) • Carotid stenosis >60% : 5 yrs stroke rate reduced from 11.8% to 6.4% • 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1) • 10 yrs stroke rate reduced from 17.9% to 13.4% • Asmptomatic Carotid Atherosclerosis Study (ACAS) A. Halliday Lancet 2004 A. Halliday Lancet 2010 JAMA 1995

  8. Carotid Endarterectomy (CEA)

  9. Emerge of Carotid artery stenting (CAS) • Excluded elderly patients (>80 yrs) with significant comorbidites • Excluded high risk lesions such as restenosis after prior CEA, radiation induced stenosis ... • CEA associated complications such as cardiovascular events, wound complications, cranial nerve injury, carotid artery dissection... Carotid Artery Stenting (CAS)

  10. Carotid artery stenting (CAS) • First case report of carotid angioplasty appeared in early 1980 Embolic-protection device in distal artery Balloon angioplasty across stenotic area Deployment of stent Withdrawl of embolic –protection device

  11. Vs

  12. 1st RCT (CEA Vs CAS) • Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS) • Performed only angioplasty without EPD • NO significant difference in 30-day incidence of death or disabling stroke (6.4% in CAS vs 5.9% in CEA) • 8 yrs follow up : Higher restenosis and stroke rate (21.1% in CAS vs 15.4% in CEA) CAVATAS Investigators Lancet 2001 CAVATAS Investigators Lancet 2009 Stenting and EPD

  13. RCTssssssss (CEA Vs CAS) CEA

  14. RCTssssssss (CEA Vs CAS) • SPACE,EVA-3S and ICSS were widely criticized • NO roll in phase e.g. SPACE trial : eligible operators for CAS arm do not need prior carotid stenting experience • Use of EPD was not mandatory e.g. SPACE trial : used in 27% of patients

  15. CREST Trial • Stenting versus Endartrectomy for Treatment of Carotid – Artery Stenosis (CREST) • National Institutes of Health-sponsored study based in United States from 2000 to 2008 • 2522 patients including both symptomatic and asymptomatic carotid stenosis • Lead in phase • Single carotid stent with EPD systems √ Thomas G. Brott N Eng Journal of Med 2010

  16. CREST – Periprocedural finding = win Thomas G. Brott N Eng Journal of Med 2010

  17. CREST – 4 years finding Thomas G. Brott N Eng Journal of Med 2010

  18. CREST Finding – Age • Younger patients have better outcome with CAS while older patients have better outcome with CEA • 120 days stroke and death risk • Age <70 yrs : CAS – 5.8% CEA – 5.7% • Age >70 yrs : CAS – 12% CEA – 5.9% • Arterial tortuosity and calcification in elderly prones to catheter provoked cerebral emboli Thomas G. Brott N Eng Journal of Med 2010

  19. CEA = CAS ?? CAS is equivalent to CEA in treatment for symptomatic and asymptomatic carotid stenosis patients Are these conclusion justified ? CAS and CEA were equally as safe and effective in terms of stroke prevention

  20. Are these conclusion justified? • Primary purpose of CEA and CAS is to prevent death and stroke

  21. Are these conclusion justified? 2. Stroke ≠ Myocardial Infarction • Quality-of-life analyses indicates that stroke had a greater adverse effect on heath-status than MI • Even minor stroke had full motor and sensory recovery, patient often have other brain damage

  22. Are these conclusion justified? 3. CAS operators in CREST have a high level of experience and skill, CREST results may not be representative in real world

  23. What is the optimal treatment in this specific patient?

  24. Matching patient to intervention • Treatment decisions depends on patient-specific factors • Risk factors for CEA • Risk factors for CAS Medical Surgical / Anatomical

  25. Risk factors for CEA • CHF and left ventricular dysfunction • Unstable angina or recent MI (<30 days) • Coronary artery disease (CAD) • Open heart surgery needed within 6 weeks • Severe pulmonary dysfunction Medical risk factors •  risk of worse outcome remains controversial • Similar stroke and death rate between low and high risk patient • Too high risk  Medical treatment Mozes J Vasc Surg 2004

  26. Risk factors for CEA Surgical / Anatomical risk factors • Surgical Factors • Restenosis after prior CEA • Previous ablative neck surgery (e.g. radical neck dissection, laryngectomy) • Previous neck irradiation • Contralateral vocal cord paralysis • Tracheostomy •  Local complications • Infection • Nerve injury • Cervical haematoma • Wound dehiscence

  27. Risk factors for CEA Surgical / Anatomical risk factors • Anatomical Factors • High carotid bifurcation (above C2) • Extension of athersclerotic lesion into intracranial ICA or proximal CCA below clavicle  Intraoperative or Peri-operative stroke

  28. Risk factors for CAS TargetVessel Arch Access

  29. Individualized management • Optimal treatment selection specific for each patient • Lowest morbidty rate • Most favorable outcomes

  30. Management Algorithm Symptomatic >= 50% CS Asymptomatic >= 70% CS LOW risk for surgery HIGH risk for surgery Favourable anatomy for CAS Unfavourable anatomy for CAS CEA CAS BMT

  31. Conclusion • CEA continues to be the gold standard for treatment for carotid stenosis • CAS will evolve as a safe and efficacious therapy for carotid stenosis • Individualized treatment plan

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