lack of evidence in carotid stenosis
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Lack of evidence in carotid stenosis management
Pascual Lozano VilardellAngiología y Cirugía Vascular
Mallorca
ESVS-SEACV Joint Session58 Congreso Nacional SEACV Barcelona 2012
Lack of evidence in symptomatic patients
When should we intervene after an ischemic stroke?
When should we intervene after an ischemic stroke?
NASCET and ECST confirmed benefit of CEA in the first two weeks after a nondisabling stroke
Current evidence suggests that surgical delay, seems to leave patients at great risk for recurrent cerebral ischemia
Rothwell PM. et al. Time from symptoms to surgery on benefit from CEA for TIA and nondisabling stroke. Stroke 2004;35:2855-2861
Rerkasem K et al. Systematic review of operative risk of CEA for recently symptomatic stenosis. Stroke 2009;40:e564-e572
When should we intervene after an ischemic stroke?
Urgent CEA in unstable patientsStroke in evolution 20,2%Crescendo TIA
11,4%
Early CEA in stable patients with TIA/minor stroke<2 weeks1,2%
CEA in stable major nondisabling stroke ?
Rockman CB et al. Early carotid endarterectomy in symptomatic patients is assocoated with poorer outcomes. J Vasc Surg 2006;44:480-7
When should we intervene after an ischemic stroke?
1158 CEAs in TIA/minor stroke
Stroke post CEA:< 4 weeks 5.1%> 4 Weeks 1.6%
p 0.002
GALA trial. Lancet 2008;372:2132-2142
When should we intervene after an ischemic stroke?
GALA trial: 15% early surgery
Stroke-MI-death post CEA:< 2 weeks 8,2%> 2 Weeks 5,1%
Stroke post CEA:< 2 weeks 6,9%> 2 Weeks 4,3%
CEA/CAS and coronary surgery
CEA/CAS and coronary surgery
Combined CEA-CABGBoth symptomatic
Staged CEA or CASCoronary symptomatic/carotid
asymptomatic
Coronary asymptomatic/carotid symptomatic
Hertzer NR. Basic data concerning associated coronary artery disease in peripheral vascular patients. Ann Vasc Surg 1987;1:616-20
CEA/CAS and coronary surgery
Naylor et al. Eur J Vasc Endovasc Surg 2003;25:380-9Naylor et al. Eur J Vasc Endovasc Surg 2009;37:379-87
30 days death/strokeCEA 10,0% (Staged = combined)
30 days death/strokeCAS 9,1% (asymptomatic)
Probably we should intervene earlyWe don’t know what to do in combinated lesions
Lack of evidence in carotid stenosis management
SYMPTOMATIC CAROTID STENOSIS
Lack of evidence in asymptomatic patients
Are the results of ACAS and ACST out of date?
ACAS. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421-1428
Halliday A et al. Prevention of disabling and fatal strokes by successful CEA in patients without recent neurologic symptoms: a randomised controlled trial. Lancet 2004;363:1491-1502
Halliday A, et al. 10-year stroke prevention after successful CEA for asymptomatic carotid stenosis (ACST-1): a multicenter randomised trial. Lancet 2010;376:1074-1084
ACAS 5,1% 11,0% 54% 84ACST 6,4% 11,8% 46% 70
10 year risk
ACST 13,4% 17,9% 26%
5 year risk CEA BMT RRR NNT
Are ACAS and ACST out of date?
ESVS, SVS, AHA…
Carotid endarterectomy is indicated in all patients with asymptomatic carotid stenosis > 60%, if periprocedural rate of death-stroke is < 3%
Are ACAS and ACST out of date?
Klein A et al. Management of carotid stenosis- polling results. N Eng J Med 2008,358:e23
Are ACAS and ACST obsolete?Are ACAS and ACST out of date?
2008
Are ACAS and ACST out of date?
Marginal surgical benefit (ARR 1%)Patient selectionNature of interventionResults “in the real world”Neurological auditoriesRol of CAS
Increased evidence for Best Medical TreatmentAggresive medical managementHealthy lifestyle
Abbott AL. Medical intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis. A systematic review. Stroke 2009;573-83
Are ACAS and ACST out of date?
What is the risk of stroke in ACS right now?
Hong K et al. Declining Stroke and Vascular Events Recurrence Rates in Secondary Prevention Trials. Circulation 2011;123:2111-2119
8,71%
4,04%
What is the risk of stroke in Asymptomatic Carotid Stenosis?
Declining of event rates per decade
Recurrent stroke 1,0 %Fatal stroke 0,3 %
Major vascular events 1,3%
Hong K et al. Declining Stroke and Vascular Events Recurrence Rates in Secondary Prevention Trials. Circulation 2011;123:2111-2119
What is the risk of stroke in Asymptomatic Carotid Stenosis?
Abbott AL. Medical intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis. Stroke 2009;40:573-583
Stroke type time Decrease
Ipsilateral stroke 1985-2007 1,7%Ipsilateral stroke/TIA 1985-2005 7%
Any stroke 1986-2007 2,3%
Any stroke /TIA 1986-2005 4,2%
What is the risk of stroke in Asymptomatic Carotid Stenosis?
Abbott AL. Medical intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis. Stroke 2009;40:573-583
ipsilateral stroke any stroke
What is the risk of stroke in Asymptomatic Carotid Stenosis?
Naylor AR. What is the current status of invasive treatment of extracraneal carotid artery disease? Stroke 2011;42:2080-85
3,5%
2,4%
1,4%
2,2%
1,1% 0,7%
What is the risk of stroke in Asymptomatic Carotid Stenosis?
ipsilateral strokeany stroke
OXFORD VASCULAR STUDY (2002-2009)
1200 patients with TIA / stroke
101 patients with ACS intensive MT
Marquardt L et al. Low risk of ipsilateral stroke in patients with ACS on best medical treatment. Stroke 2010;41:11-17
What is the risk of stroke in Asymptomatic Carotid Stenosis?
Annual ipsilateral stroke rate 0,34%
There are patients at high stroke risk?Can we identify this patients?
There are patients at high stroke risk?Can we identify this patients?
Clinical features
Degree of stenosis
Progression of stenosis
Plaque characteristics
Cerebrovascular reactivity
Microembolism
Silent infarcts
Biomarkers
Hirt LS. Stroke. 2011;42Nicolaides AN et al. Eur J Vasc Endovasc Surg. 2005;30:275-284
Independent risk predictors of ipsilateral events:
- Previous contralateral events (21.6% vs 14.7%)
- History of contralateral TIAs (RR 3.0; 95% CI 1.90-4.73)
There are asymptomatic patients at high risk of stroke?Clinical features
Kakkos SK et al. J Vasc Surg 2009;49:902-9Rijbroek A et al. Eur Neurol 2006;56:139-154
Neither ACAS nor ACST demonstrated any relationship between stenosis severity and late risk of stroke
Discrepance with other natural history studies: Degree of stenosis identified as an independent predictor of ipsilateral neurologic events (p=0.019)
There are asymptomatic patients at high risk of stroke?Degree of stenosis
There are asymptomatic patients at high risk of stroke?Progression of stenosis
Hirt LS. Progression rate and ipsilateral neurological events in ACS. Stroke 2011;42
Jayasooriya G et al. J Vasc Surg 2011;54:227-36
There are asymptomatic patients at high risk of stroke?Carotid plaque vulnerability: MICROEMBOLISM
Markus HS et al. Asymptomatic embolisation for prediction of stroke in the ACES: a prospective observational study. Lancet Neurol 2010;9:663-671
Patients with MES Mean number MES
10% 2,63 (1-20)
There are asymptomatic patients at high risk of stroke?Carotid plaque vulnerability: MICROEMBOLISM
ipsilateral stroke
MES 3,62%No MES 0,70%
Spence JD et al. Effects of Intensive Medical Therapy on Microemboli and Cardiovascular Risk in ACS. Arch Neurol 2010;67:180-86
Patients with MES Carotid plaqueprogression
Cardiovascular events
2000-2002 12,6% 69 mm2 17,6%2003-2007 3,7% 23 mm2 5,6%
There are asymptomatic patients at high risk of stroke?Carotid plaque vulnerability: MICROEMBOLISM
Intensive medical therapy
468 patients with ACS > 70%
There are asymptomatic patients at high risk of stroke?COMBINATION SCORES: ACES
Topakian R et al. Neurology 2011;77:751-758
ipsilateral stroke
Echolucency + MES 8,90%None 0,80%
Nicolaides AN et al. ACS and cerebrovascular risk stratification. J Vasc Surg. 2010;52:1486-96
There are asymptomatic patients at high risk of stroke?COMBINATION SCORES: ACSRS
a)Stenosis alone: 0.59b)Stenosis + clinical features (smoking, contralateral stroke/TIA): 0.66c)Stenosis + plaque characteristics + previous contralateral TIA/stroke: 0.82
There is place for angioplasty in ACS?
There is place for angioplasty in ACS?
CREST ASYMPTOMATIC periprocedural 4 yearsCEA 1,4% 2,7%CAS 2,5% 4,5%
Death-stroke. MI excluded
Brott et al. Stenting versus endarterectomy for treatment of carotid artery stenosis. N Eng J Med 2010;363:11-13
There is place for angioplasty in ACS?
periprocedural SVS REGISTRY
CEA 2,0 %CAS 4,6 %
Combined death-stroke-MI
Giles KA et al. Stroke and death after CEA and CAS with and without high risk criteria. J Vasc Surg 2010;52:1497-1504
ACAS and ACST results are being questionedWe don’t know the exact risk of stroke of ACSProbably there are patients at very low stroke riskProbably there are patients at high stroke riskWe don’t have standardized methods to identify this patientsProbably no place for rutinary CEA or CAS in ACS
Lack of evidence in carotid stenosis management
ASYMPTOMATIC CAROTID STENOSIS
So we need more RCT in Asymtomatic Carotid Stenosis
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