Surgical Intervention for Carotid Artery Disease

1. Surgical Intervention for Carotid Artery Disease Mr Gabriel Sayer Consultant Vascular Surgeon

2. Aims • Discuss the role Carotid Artery Stenosis (CAS) in the development of stroke • Review different treatment modalities for CAS • Appraise best practice guidelines • Identify how we can reduce strokes secondary to carotid artery stenosis in our patient population

3. Why is carotid artery stenosis important? • Risk factor for embolic stroke • Risk factor for ischaemic heart disease • Should therefore consider secondary prevention measures in all patients who have any carotid artery stenosis

4. What is a carotid stenosis and how do we define it?? • Historical perspective • Clinical evaluation • Diagnostic modalities • Symptomatic ?

5. Carotid Artery Stenosis (CAS) and Stroke • Historically it was felt that CAS was associated with an increased risk of stroke • Diagnosis was difficult (combination of clinical and angiography) • Fischer M noted that often the carotid vessel distal to the stenosis was normal calibre

6. Carotid angiography But angiography had a procedural stroke risk of 0.1-1%

7. Carotid Duplex Scanning

8. CTA and MRA

9. What is a symptomatic CAS? • ANY CAS associated with development of focal neurological episode in the area supplied by the corresponding middle cerebral artery or branches thereof

10. Carotid Artery Stenoses • Symptoms due to narrowing of the Internal Carotid Artery • The narrowing may be irregular promoting production of ‘emboli’ • Patients may suffer Amaurosis Fugax, TIAs or CVAs due to impaired blood supply to the brain

11. Treatment options • Ligation • Bypass • Endarterectomy

12. First Carotid Endarterectomy

13. DeBakey- the greatest surgeon ever? • Worked under Leriche in Strasbourg and Kirschner in Heidelberg • Worked throughout europe during WWII culminating in the development of MASH units • First ever aortic aneurysm repair (1953) • First ever CEA (1953?) • First coronary artery bypass (1964) • First ventricular assist device (1966) • First multi organ transplant ….

14. The british version • 66 y.o female presented with recurrent bouts on LEFT monocular blindness and RIGHT hemiplegia • Professor Pickering organised a carotid angiogram • Professor Charles Rob supervised his Assistant director Felix Eastcott who undertook the operation

15. Carotid Endarterectomy

16. Carotid Endarterectomy

17. Carotid Endarterectomy

18. How do we do surgery for CAS? • Local or General anaesthetic? • Patch or not? • Shunt or not? • Eversion or open endarterctomy?

19. Results count, Method is secondary • GALA trial shows no benefit of LA over GA!

20. Carotid Endarterectomy- high risk patients • Challenging Anatomy • High carotid bifurcation • Distal disease • Redo operations • Previous surgery or RXT to neck or cranial nerve injury (esp RLN) • Crescendo TIAs • Medical comorbidity

21. What is evidence for treatment? • ESCT/NASCET • ACST

22. Level 1 Data in support of CEA as treatment for symptomatic CAS • Doubt over efficacy of the treatment and the advent of managed care led to two trials ECST and NASCET 1991 • Results are now 17 yrs old! • Selected population • Very little risk factor modification

23. NASCET Vs ECST • NASCET • 1-a/b x 100 = stenosis % • ECST • 1-a/c x 100 = stenosis % So ECST gives greater percentage of stenosis for same lesion

24. ECST/NASCET a brief summary

25. ECST/NASCET • Selective criteria for trial e.g. <80 years • NASCET approval required for surgeons • How applicable are these trials to real life

26. What about asymptomatics CAS? • Casanova 1991 • Veterans affairs study group 1993 • ACAS 1995 • And now the ACST 2005

27. ACST Summary • Significant reduction of stroke risk in asymptomatics CAS >70% with CEA • Procedural risk <3% major stroke or death • ACST • All stroke reduction of 6.4% versus 11.8% • 3.5% versus 6.1% for fatal or disabling strokes (net gain 2.5%) NNT=40

28. The End of Carotid Endarterectomy? • Now we can stent them • Is this better? • Is it suitable for all? • Does it last as long? • Should we do asymptomatics?

29. Potential advantages of carotid stenting • Reduced hospital stay • No wound complications • No cranial nerve injury vs 3-7% for CEA • Reduced cardiovascular complications

30. BUT.. • Is it durable? • Is there a higher procedural risk of stroke? • Up to 60% not suitable

31. Evidence • CAVATAS • LEICESTER • WALLSTENT • LEXINGTON Symptomatic and Asymptomatic • EVA-3S • SAPPHIRE • SPACE • ICSS (CAVATS II)

32. What is Cerebral Protection?

33. CAS Vs CEA • CEA is proven procedure • CAS has variable results although they appear to be improving with better kit and knowledge base • CAS probably has a 7-10% major stroke/death rate for symptomatic >70% • CAS not suitable for all

34. CEA vs CAS • The jury is still out and CAS remains the gold standard at present • ICSS trial will report soon and will shed further light on this area

35. When should we treat patients with intervention? • Within 6 months? • Within 2 weeks? • Within 2 days?

36. Problems with urgent surgical intervention

37. How we can reduce strokes secondary to carotid artery stenosis in our patient population ?

38. Developments here at Queens