Transcript Document

What is the Better
Option in Treatment
of Carotid Artery
Stenosis?
Carotid
Endarterectomy
(CEA)
Or
Carotid Artery
Stenting (CAS)
Jake High
Katelin Hower
Amaurosis Fugax
• Latin for “fleeting blindness”
• Transient and complete unilateral loss of vision
lasting seconds to minutes
• “Blind being pulled down” suddenly
• Painless
• Common Causes:
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CAS
Heart valve dz
Cardiac arrhythmias
Atrial/ventricular thrombus
• Why is this important:
– It is a precursor of stroke!!!!
(Sean, 2013)
What is Carotid Artery Stenosis?
(CAS)
• Narrowing of the carotid arteries
• Risk factors:
– Family Hx of atherosclerosis, Age > 75, High
LDL, Smoking, HTN, DM, Obesity, Sedentary
lifestyle
• Signs and Sx warning signs of stroke
– Amaurosis fugax
– Weakness/numbness of one side
of the face/arms/legs
– Slurred speech, difficulty talking
– Loss of coordination
(Joseph, 2013)
What is Carotid Artery Stenosis?
(CAS)
• Physical exam – carotid bruits
– Just because you don’t hear them doesn’t
mean it is not there
• Diagnostic Imaging
– Carotid duplex US, carotid angiography,
MRA, CT scan, or CTA
(Joseph, 2013)
What is the Carotid Circulation?
(The Brain, 2011)
(Circulation Foundation,
2013)
(Lynch, 2013)
Transient Ischemic attack (TIA) and
Cerebral Vascular Accident (CVA)
•#3 cause of death
•#1 disabling disease in America
•85% of CVA are due to ischemia from
occlusion or stenosis
•15% of CVA are due to hemhorrage
•TIA is “an acute episode of focal loss and
cerebral function usually lasting less than 10
minutes”
•After having a TIA PT’s are at substantially
increased risk for CVA, 5.1% of CVA within 48
hours of the TIA
(Joseph, 2013)
PICO
In symptomatic patients with carotid
artery stenosis needing surgical
intervention, which has the greatest
advantageous therapeutic outcome in
terms of peri-operative cardiovascular
events, post-operative cardiovascular
events, and restenosis, carotid artery
stenting or carotid endarterectomy?
Carotid Endarterectomy (CEA)
• Indications for procedure
• Proven Indications
• One or more TIAs in the last 6 months and
carotid stenosis ≥70%
• Mild stroke with carotid stenosis ≥70%
• Acceptable But Not Proven Indications
• TIAs in the past 6 months and stenosis of
50% to 69%
• Progressive stroke and stenosis ≥70%
• Mild or moderate stroke in the past 6
months and stenosis of 50% to 69%
• Carotid endarterectomy ipsilateral to TIAs
and stenosis ≥70%, combined with required
coronary bypass grafting
(Khatri, 2003)
Carotid Endarterectomy (CEA)
• Risks
- MI
- Hyperperfusion Syndrome
- Stroke - Nerve Damage
- Parotitis - Infection
- Death
• Benefits
- Ultimately to prevent stroke and death
(Khatri, 2003)
CEA Surgical Procedure
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Skin, subQ tissue, platysma m. divided with electrocautery
Greater auricular nerve identified and preserved
Retractor placed to displace scm for better exposure
Common facial vein identified and ligated
Internal jugular vein is dissected laterally for access to carotid artery
Hypoglossal and vagus N identified and preserved
Carotid sinus injected with 1% lidocaine to prevent hypotension and
bradycardia
Systemic heparin bolus 5000 units and common, internal, external
carotid arties clamped
Arteriotomy from common carotid extended into internal carotid
artery
Shunt placed internal carotid artery and proximal end to common
carotid, restoring cerebral blood
Proximal plaque transected with scissors and continued distally, then
flushed with heparinized saline
Shunt removed, and vessels flushed, external first, common, then
internal to minimize cerebral embolization
Closed with 6-0 polypropylene and thrombin
(Khatri, 2003)
Carotid Artery Stenting
• Indications:
– patients who are at an increased risk with carotid
surgery (severe heart disease, heart failure, severe
lung disease, age > 75/80, etc.).
– Neurologic symptoms with > 50 percent stenosis of
the common or internal carotid artery (symptomatic)
– No neurologic symptoms but > 80 percent stenosis of
the common or internal carotid artery (highly
symptomatic)
– Damage to contralateral vocal cord from previos CEA
– Previous surgery of the ipsilateral side
– Neck irradiation
– Restenosis after CEA
(Daroff, 2012)
Carotid Artery Stenting
Risks:
• Stroke.
• Heart attack.
• Bleeding at the catheter insertion site.
• Damage to the blood vessel at the
catheter insertion site.
• Infection.
• Restenosis
• Death.
Benefits:
• Prevents stroke
and death
(Daroff, 2012)
Carotid Artery Stenting
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Preparation of both groins with antiseptic and draped
Puncture into femoral artery and access through short sheath
Guidewire passed through aorta and into arch
Arch aortogram obtained if not previously performed to confirm
suitability to continue
Carotid and cerebral angiogram performed
Long access sheath placed after cannulation of common carotid
artery (CCA)
Guidewire passed through area of carotid narrowing
Placement of embolic protection device to prevent debris reaching
the brain
Angioplasty of carotid narrowing
Stent deployment
Angioplasty after stent deployment
Removal of protection device, guidewires and sheath
(Daroff, 2012)
Research
Journal
Results
Restenosis after carotid artery
stenting and endarterectomy: a
secondary analysis of CREST, a
randomised controlled trial
CREST compared CVA, MI, and death: CEA and stenting– no significant difference
Eligible participants – asymptomatic CAS, TIA, amaurosis fugax, or minor stroke
Results: 6.0% of stenting and 6.3% of CEA pts had restenosis/occlusion after 2 yrs
Risk factors: female gender, diabetes, dyslipidemia, Smoking was a risk factor for
CEA restenosis, but not stenting
Carotid endarterectomy and
carotid artery stenting utilization
trends over time
Relative benefits of each procedure based on each pt’s profile
Stenting > CEA in pts age < 70 with high surgical risk
CEA > stenting – symptomatic pts > 70yrs
Stenting versus Endarterectomy
for Treatment of Carotid-Artery
Stenosis
Randomly assigned patients with symptomatic or asymptomatic carotid stenosis to
undergo carotid-artery stenting or carotid endarterectomy. There was no significant
difference in the estimated 4-year rates . Total of 2502 over median 2.5 years. The 4year rate of stroke or death was 6.4% with stenting and 4.7% with endarterectomy.
Periprocedural rates of death 0.7% CS, 0.3%CEA, stroke 4.1% CS, 2.3% CEA, MI
1.1% CS and 2.4% CEA. Study found no significant differences between CS and
CEA. Did note higher risk of stroke in CS and MI in CEA.
Research
Journal
CEA versus CAS: short-term and
mid-term results
Results
300 patients involved in this study over a total of 3 years. Posteroperative events
CEA vs CS were as follows: neurological deficit: 1.3% vs. 3.3%, embolic lesions at
postoperative MRI: 4% vs. 34% and worsening of cognitive tests: 4% vs. 25.3%.
Study found the CEA was the treastment of choice due to lower rates or morbidity
and mortality.
A Systemic Review and MetaAnalysis of Randomized Trials of
Carotid Endarterectomy vs
Stenting
A meta-analysis was done including a total of 7484 patients. 80% of the total patient
population has symptomatic disease. With a 95% confidence interval, they study
found the compared to carotid endarterectomy, carotid artery stenting had a
significant increase in stroke and a non-significant decrease in myocardial infarction.
The Effect of Postoperative
Stroke and Myocardial Infarction
on Long-term Survival after
Carotid Revascularization
New England Vascular group used CEA and CS results from 2003 to 2011.
Concentrating on significant events within 5 years time frame. The study included a
total of 8,315.
Perioperative Events
Study
CAVATAS
Date
March 1992July 1997
NASCET
August
1999- June
2010
EVA-3S
November
2000September
2005
# CAS
251
242
# CEA
253
265
Adverse
Event
% CAS
%CEA
Stroke
0.5% (3n)
0
MI
0
0
Death
0
0.5% (3n)
Stroke
11.1% (120n)
6.2% (67n)
MI
0
0
Stroke
9.9% (24n)
3.3% (9n)
MI
0.41% (1n)
0.75% (2n)
Death
0.41% (1n)
0.37% (1n)
Postoperative Events
Study
Date
SPACE
March 2001February
2006
CAVATAS
SCEV
March 1992July 1997
January
1995December
2006
# CAS
599
251
261
# CEA
584
253
259
Adverse
Event
% CAS
%CEA
Stroke
7.5% (45n)
6.2% (36n)
MI
0
0.5% (3n)
Death
0.1% (1n)
0.3% (2n)
Stroke
26.7% (67n)
19% (48n)
MI
0
1.2% (3n)
Death
44.6% (112n)
44.6% (113n)
Stroke
8.8% (23n)
2.7% (7)
MI
0.38% (1n)
0.77% (2n)
CN injury
1.1% (3n)
7.7% (20n)
Death
0.77% (2n)
1.1% (3n)
Restenosis
Restenosis
Study
Date
# CAS
#CEA
Percent
Restenosis
CAS
Percent
Restenosis
CEA
CAVATAS
March 1992July 1997
50
213
16.6%
10.5%
SAPPHIRE
August 2000July 2002
143
117
3%
7.1%
EVA-3S
November
2000September
2005
242
265
3.3%
2.8%
CREST
December
2000- July 2008
1086
1105
6%
6.3%
SPACE
March 2001February 2006
541
522
11.1%
4.6%
Conclusion
Carotid endarterectomy has long been the
“gold standard” for treatment of carotid artery
stenosis. With the continued development of
technology, carotid stenting has begun to rival
the standard. Strokes, MIs, and death are the
most frequent and severe risks involved with
both procedures. In every study analyzed, the
risk of stroke was higher in the stenting group,
while MIs showed a very mild increase in
prevalence in endarterectomy. Unless a patient
has other comorbidities that make the risk of
surgery too great, carotid endarterectomy is still
the “gold standard” for carotid artery stenosis.
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Resources
The Brain Aneurism Foundation. (2011). Understand brain aneurysm. Retrieved from www.bafound.org
Brajesh, K.L., Beach, K.W., Roubin, G.S., Lutsep, H.L, Moore, W.S., Malas, M.B., …Brott, T.G. (2012). Restenosis After Carotid Artery Stenting
and Endarterectomy: a secondary analysis of CREST, a randomized controlled trial. Lancet Neurol 11, 755-763.
doi:http://dx.doi.org/10.1016/S1474-4422
Brott, T.G., Hobson, R.W., Howard, G., Roubin, G.S., Clark, W.M., Brooks, W., … Meschia, J.F. (2010). Stenting Versus Endarterectomy for
Treatment of Carotid-Artery Stenosis. New England Journal of Medicine, 363 (1).
http://www.nejm.org/doi/full/10.1056/NEJMoa0912321
Circulation Foundation. (2013). Carotid vascular disease. Retrieved from http://www.circulationfoundation.org.uk/
Daroff, R. (2012). Treatmentof acute ischemic stroke. (6th ed., Vol. 2). Philadelphia, PA: Elsevier Saunders. Retrieved from
http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-1-4377-0434-1.00112-2&isbn=978-1-4377-0434-1&uniqId=41097508211
Felli, M.M., Alunno, A., Castiglione, A., Malaj, A., Faccenna, F., Jabbour, J., … Gossetti, B. (2012). CEA versus CAS: short-term and mid-term
results. International Journal of Angiology, 31 (5), 420-6. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/22990503
Joeseph, O. (2013). Carotid stenosis. (1st ed., Vol. 5, pp. 433-38). Philadelphia, PA: Elsevier Mosby. Retrieved from
http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-0-323-08373-7.00012-1--sc23015&isbn=978-0-323-083737&sid=1439751102&uniqId=410975082-4
Joeseph, O. (2013). Transient Ischemic Attack. (1st ed., Vol. 5, pp. 433-38). Philadelphia, PA: Elsevier Mosby. Retrieved from
http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-0-323-08373-7.00012-1--sc23015&isbn=978-0-323-083737&sid=1439751102&uniqId=410975082-4
Khatri. (2003). Carotid endarterectomy. (1st ed.). St. Louis, MO: W.B. Saunders Company. Retrieved from
http://www.mdconsult.com/books/page.do?eid=4-u1.0-B0-7216-7864-5.50001-8&isbn=0-7216-7864-5&uniqId=410975082-9
Lynch, P. (2013). Carotid arteries. Retrieved from http://biology.about.com/od/anatomy/ss/carotid-arteries.htm
Mantese VA: The carotid revascularization endarterectomy versus stenting trial (CREST). Stenting versus carotid endarterectomy for carotid
diseaseStroke 2010; 41:S31-S34.
Murad, M.H., Shahrour, A., Shah, N.D., Montori, V.M., and Ricotta, J.J. (2011). A Systemic Review and Meta-Analysis of Randomized Trials of
Carotid Endarterectomy vs Stenting. Journal of Vascular Surgery, 53 (3), 792-7. Retrieved from:
http://www.ncbi.nlm.nih.gov/pubmed/21216556
Sean, S. (2013). Amaurosis fugax. (1st ed., Vol. 5, p. 362). Philadelphia, PA: Elsevier Mosby. Retrieved from
http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-0-323-08373-7.00002-9&isbn=978-0-323-083737&uniqId=410975082-3
Simons, J.P., Goodney, P.P, Baril, D.T., Nolan, B.W., Hevelone, N.D., Cronenwett, J.L., Messina, L.M., & Schanzer, A. (2013). The Effect of
Postoperative Stroke and Myocardial Infarction on Long-term Survival after Carotid Revascularization. Journal of Vascular Surgery.
Doi: 10.1016/j.jvs.2012.11.118. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/23402875
Skerritt, M.R., Block, R.C., Pearson, T.A., & Young, K.C (2012). Carotid Endarterectomy and Carotid Artery Stenting Utilization Trends Over
Time. BMC Neurology, 12 (17). Retrieved from: http://www.biomedcentral.com/1471-2377/12/17