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Saturday, September 29 Saturday, September 29 NOTES— Debate: Surgery Will Always be the Right Option Steven Bolling, MD Debate: The Future is PCI Cindy Grines, MD Debate: Surgery Will Always be the Right Option—Rebuttal Steven Bolling, MD Debate: The Future is PCI—Rebuttal Cindy Grines, MD 9/17/2012 OPTIMAL MANAGEMENT OF CAROTID ARTERY DISEASE: Carotid endarterectomy vs. stenting Jean Starr, MD, FACS, RPVI Associate Professor of Clinical Surgery Division of Vascular Diseases and Surgery Director of Endovascular Services Objectives Stay awake General stroke stats Stay awake Ischemic causes Stay awa ke Workup Stay wake Treatment options Fun vascular facts Brain is 2% of total body weight Brain consumes 25% of inspired oxygen and 15% of total cardiac output Brain has more significance in women OK…I made that up Circle of Willis incomplete in 50% in autopsy studies Cerebral blood flow is under tight autoregulation to maintain perfusion pressure 1 9/17/2012 Striking Stroke Statistics Incidence Every 45 seconds someone in the U.S. has a stroke. Each year 700,000 people experience a stroke. 500,000 are first attacks and 200,000 are recurrent attacks. Each year about 40,000 more women than men have a stroke. African-Americans have almost twice the risk of first-ever stroke compared to whites. Heart Disease and Stroke Statistics – 2004 Update, American Heart Association, 2004, pgs 13-15. Striking Stroke Statistics Mortality Stroke accounts for more than 1 of every 15 deaths in the U.S. (150,000 annually) Stroke ranks no.3 among all causes of death behind diseases of heart and cancer. On average, every three minutes someone dies of a stroke. Because women live longer than men, 61% of deaths from stroke in 2001 were females. Heart Disease and Stroke Statistics – 2004 Update, American Heart Association, 2004, pgs 13-15. Striking Stroke Statistics Aftermath Stroke is the leading cause of serious, long-term disability in the U.S. In 1999, more than 1,100,000 Americans reported difficulty with functional limitations resulting from strokes. Cost In 2004 the estimated direct and indirect cost of stroke is $53.6 billion. The mean lifetime cost of ischemic stroke in the U.S. is $140,000. Heart Disease and Stroke Statistics – 2004 Update, American Heart Association, 2004, pgs 13-15. 2 9/17/2012 Carotid Epidemiology – 2005 (US)1 2.46 million with >50% carotid stenosis2 10% 90% 3 Symptomatic Asymptomatic4 74,000 172,000 266,000 1,510,000 Undiagnosed Diagnosed/yr Diagnosed/yr Undiagnosed Need to get 438,000 diagnosed/yr Need to get patients patients diagnosed diagnosed 1. Numbers reflect epidemiology of United States only. 2. Primary Prevention of Ischemic Stroke, Circulation, 2001;103:1632001;103:163--182.182. 3. Endarterectomy for Asymptomatic Carotid Artery Stenosis, JAMA, 1995. Vol 273, No. 18. P.1421P.1421--1428.1428. 4. New Insights on Stroke Prevention in Patients without Symptoms. London, Ontario. June 7, 2000. Prevalence of Stroke Prevalance of Stroke by Age and Sex 12.0 11.5 12 NHANES: 1999-2002 10 tion 8 Men a 666.6 Women 636.3 6 4 3.1 3.0 % of Popul of % 2.1 2 1.1 0.8 1.2 0.4 0.34 0 20-34 35-44 45-54 55-64 65-74 75+ Ages Heart Disease and Stroke Statistics – 2006 Update, American Heart Association, 2006, pg 88. 8 Ischemia may be caused by: Embolic occlusion - caused by thrombus, platelet aggregates, and atheromatous debris May be related to intraplaque hemorrhage, ulceration of plaque with exposure of underlying debris and deposition of thrombus Arterial thrombosis (()less common) Originates from critical stenosis and propogates proximally and distally to the next major collateral (external prox and ophthalmic dist…will not continue into MCA unless ophthalmic flow is poor) Reduction in total cerebral blood flow May present with nonlateralizing cerebral ischemic attacks (ataxia, bilateral symptoms, homonymous hemianopsia, drop attacks) 3 9/17/2012 Diagnostic evaluation Physical examination BP in both arms; orthostatics Cardiac rate and rhythm Murmurs assoc. with valvular disease or septal defects Pulses in cervical, upper and lower extremity Pulsatile masses and thrills Cervical/supraclavicular bruits; 40% of pts. with stenosis have bruit; 20% of pt. with a bruit will have a significant stenosis General vascular exam Carotid duplex Initial study of choice (non-invasive, painless, readily available) High resistive signal in ECA and low resistance in ICA Degree of stenosis and character of the atheroma (color flow and B- mode imaging) Dense calcium may obscure the results Limited ability to predict ararchch and intracranial disease Many perform CEA based on duplex imaging alone Utility for post-procedural follow up CT Angiography May be more precise than MRA; gives information on inflow Calcium may obscure the results Utilizes radiation and contrast Motion artifacts Images dependent on post-processing 4 9/17/2012 MRA Physiologic evaluation of blood flow (indirectly evaluates vascular anatomy) Limited with complex, turbulent, minimal flow (such as at carotid bulb), ulcerations, tandem lesions, orificial lesions May overestimate degree of stenosis Non-invasive, can evaluate cerebral anatomy, avoids iodinated contrast, less operator variability than with duplex imaging, techniques can vary between centers, CLAUSTROPHOBIA Nephrogenic systemic fibrosis Magnetic Resonance Angiography 14 Angiography ?Gold standard Invasive (although risks are low: 1.2% in ACAS) Involves contrast and radiation Diagnose and treat during the same setting BttBetter vesse ldlil delinea tion 5 9/17/2012 Ulceration 16 ANGIOGRAPHY DSA CTA MRA 17 Treatment history 1875 – Gowers linked stroke to carotid artery disease 1937 – carotid artery occlusion could be diagnosed by angiography 1953 – first unsuccessful attempt at endarterectomy of totally occluded artery 1954 – first successful carotid reconstruction (resection and anatomosis by Eastcott, Pickering, and Robb) 1951 – Carrera – resection and anastomosis to ECA; not reported until 1955 1953 - DeBakey and Cooley – CEA but not published until 1975 and 1956 6 9/17/2012 Medical treatment Antiplatelet therapy ASA, ticlopidine, dipyridamole/ASA, clopidigrel Anticoagulant therapy No data that it is beneficial for stroke prevention except in thromboembolic stroke due to afib Potential use in crescendo TIA No randomized studies utilizing best medical management with these drugs and statins Surgical treatment Carotid endarterectomy General vs regional or local anesthesia Weigh patient anxiety and potential for longer operation vs. ability to assess neurologic function and decreased anesthetic risks Positioning: slight neck hyperextension, turned to opposite side, reverse Trendelenberg Maintaining cerebral blood flow (“To shunt or not to shunt”) Surgical treatment Carotid endarterectomy (cont.) Vagus nerve may spiral anteriorly Common facial vein marks the bifurcation Lidocaine standing by for carotid body and sinus Avoid manipulation of carotid bifurcation Mobilize distal ICA beyond disease Identify CN XII; potentially divide posterior belly of the digastric 7 9/17/2012 Carotid Endarterectomy 22 Surgical treatment Complications Hematoma – 0.7-1.5% incidence Infection – 0.09% Post-op hyper- or hypotension – neurons in the bulb adventitia, transmitted by nerve of Hering (CN IX) Peripheral nerve palsies: 7% RLN, 6% hypoglossal, 2% MM, 2% SLN, greater auricular, glossopharyngeal… 33% were asymp (CCF study). Most recover in 3 mos. TIA/CVA – 3, 5, and 7% Asymptomatic thrombosis – 2-18% Intracranial hemorrhage – several days post-op, devastating Post-op seizure – excruciating unilateral headache Cardiac events Endovascular management Carotid stenting Stenotic artery is opened and plaque “wallpapered” to vessel wall FDA approved for surgical high and standard risk patients (but not necessarily reimbursed by CMS) Several systems available Distal protection required for reimbursement High operator learning curve; requires advanced endovascular skills Can be done with local anesthesia 8 9/17/2012 High Risk Criteria Anatomic criteria Previous neck dissection or radiation High or low lesion Recurrent carotid stenosis after CEA Contralateral carotid occlusion Medical criteria Unstable angina Recent MI Class III/IV heart failure Severe lung disease Need for CABG Age > 80 Carotid Artery Stenting Advantages Treatment option for patients contraindicated for CEA Avoids the risk of cranial nerve damage Does not require general anesthesia Disadvantages Currently there are fewer experienced clinicians Not all patients are suitable for carotid stenting Severe aortic arch and supra-aortic vessel tortuosity Thrombus Very long severe lesions String sign Heavy circumferential calcification Arch Types 9 9/17/2012 Carotid Stenting Overview FDA approved 2004 Alternative treatment for high risk patients Uses 0.014 wire and distal embolic protection device Early clinical investigations had poor outcomes Initial approval based mostly on industry– sponsored trials and compared to historic surgical trials Randomized comparisons recently completed (CREST) Requires antiplatelet therapy Overview of Stent Procedure Steps Percutaneous femoral arterial access Arch and selective carotid angiography if not previously performed Guide catheter/sheath placement in CCA Neurologic assessment each step of the way (“Squeeze the duck”) Embolic protection device positioned beyond carotid stenosisPre-dilatation using an appropriately-sized balloon catheter
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