Carotid surgerypast present future

J M CARDON

PRIVATE HOSPITAL FRANCISCAINES

NIMES FRANCE

Now in russia

First cause of mortality cardiac events: 683 170

Second stroke : 372 534

Third cancer: 293 602

Infografika 2012

The past

TCMM

1977 Easton JD

21,1%

And now

TCMMSérie Historique

1977 Easton 6,5 %

2,8 %

2,8%

2006 EVA 3S 3,9 %15000 cases in France

NASCET 1991

ACAS 1995

EVA 3 S 2006

INDICATIONS4 randomized study

Symptomatic stenosesNASCET 2885 patients 1987-1996ECST 3024 patients 1981-1994

Asymptomatic stenosesACAS1659 patients 1987-1993ACST3125 patients 1995-2003

INDICATIONS symptomatic stenoses

Sténoses > 70 %NASCET 2885 patients NEJM 1991ECST 3024 patients Lancet 1991

↓ R. Abs ↓ R. Relat NST / 1 stroke

strokeAvoided for1000 CEA

NASCET

17 % 65 % 6

170

ECST 8,5 %* 45 % 12 83

Symtomatic stenoses

Symptomatic stenoses

Sténoses 50-69 %NASCET 858 patients NEJM 1998ECST 646 patients Stroke 2003

↓ R. Abs ↓ R. Relat NST / 1 sroke

srokePrevented by

1000 CEA

NASCET

8,4% 26% 12

83

ECST 5,7% - - -

SYMPTOMATIC STENOSES

SOME SUBGROUPS HAVE

MORE BENEFIT FROM

SURGERY

Age > 75 (Nascet NST 3 vs 6)

stroke vs TIA

men vs women

central vs retineal

symptomatic stenoses

Résults of surgery according to delay from symptoms

No statiscal differrence in TCMM

<2 sem 2-4 sem 4-12 sem>12 sem

p

ECST 6,5% 6,4% 7,4% 8% 0,86

NASCET 7,1% 5,0% 6,5% 7,4% 0,64

Total 6,9% 5,7% 7,0% 7,8% 0,48

But the sooner is the better

Reduction of absolute risk of stroke and mortality at 5 years according to the delay of surgery

Rothwell : stroke 2004

INDICATIONS TIA

Stroke risk

7 days 10 %30 days 15 %

TIA is an emergency Angio MRI or scan in less than 24

h Duplex doppler Cardiac screening Hospitalisation if ABCD2 ≥ 3

INDICATIONS asymptomatic stenoses

Randomized controlled trials

CEA vs BMT ACAS 1995 Jama

ACST-1 2004 Lancet2010

Level 1 grade A evidence supporting CEA

In highly selective asymptomatic patents with a stenosis > 60 % CEA conferred a 50 % relative risk reduction of stroke at 5 years

asymptomatic stenoses

Sténoses > 60 %ACAS1662 patients JAMA 1995ACST3120 patients Lancet 2004

↓ R. Abs ↓ R. Relat NST / 1 AVC

strokeAvoided for1000 CEA

ACAS 5,9 % 53 % 19 53

ACST 5,4 % 45 % 18 54

ACTS – 1 : 10 years

asymptomatic stenoses

Subgroup analysis Degre of stenosis does not influence the results

better for men vs women (↓ r.a 8 / 1,4 %)

benefit arrive after 1 years

younger <75 years have more benefit than older

asymptomatic stenoseswhat about best medical treatment ?

USA 2005

Endartériectomie 135 701

92 % asymptomatique

With the use of statins in ACTS-1 The evidence of stroke fell strongly in the

medical arm

But it fall strongly as well is the CEA arm. So the difference is still highly significant

NO BENEFIT FROM CEA

Symptomatic Asymptomatique

< 50% NASCET < 60% NASCET

EASY INDICATION

STRONG INDICATION SYMPTOMATIC STENOSES >

75%

R. Abs R. Relat NST / 1 stroke

strokeAvoided by1000 CEA

NASCET

17 % 65 % 6

170

ECST 8,5% 45% 12 83

R. Abs R. Relat NST / 1 stroke

Stroke avoided by 1000

CEA

Sténoses Symptomatic

50-69 % NASCET

6,5% 29% 15

67

Sténoses Asymptomatic> 60 % NASCET

5,9% 53% 17

59

DISCUSSION

In summery : indications TIA are emergencies

Symptomatic patient have to be treated within 15 days

The degree of stenosis does not influence the stroke risk in asymptomatic patient with stenosis >60%

TCMM must be < 3% to operate asymptomatic patient

TECHNICAL EVOLUTION OF CEA

N TCMM Resténose ou occlusion

Ballotta1999

Eversion 169 0 0Patch 167 2,3% 4,9%

Green 2000

Eversion 107 0,9% 4,6%Patch 167 3% 4,7%

Everest Trial2000

Eversion 678 2,2% 3,6%EC 675 1,6% 9,2%

Cochrane DB2003

Eversion 1190 1,7% 2,5%EC ± patch 1173 2,6% 5,2%

EVERSION

Pour

LESS RESTENOSIS

NO CLINICAL BENEFIT

SURGEON CHOICE

Notre opinion

TECHNIC Eversion

G

TECHNIC Patch versus direct SUTURE

N TCMMperiop

TCMMFw-up

Resténose occlusion

Patch 936 2,3 % 13 % 4,3 %

Suture directe 833 3,7 % 20 % 13,7 %

NS S S

2009

2009

MAY REDUCE RESTENOSIS AND OCCLUSION RATE

REDUCE IPSILATERAL POST OP STROKE RATE

REDUCTION IN POST OP TCMM RATE

WHAT PATCH ?

Dacron Collagène vs PTFE

2004

CEREBRAL PROTECTION

2009

Avantage : hémodynamic and morphologic

data

PER-OP CONTROLDUPLEX SCAN

N Abnormalities FU(mois)

RESTENOSENormal vs minor

abnormal

Baker1994

316 19,6% 21,6 4,3% vs 17%

Ascher2004

650 2,3% - -

comparative study

angio No angio

N TCMM % N TCMM %

Roon

1992

535 1,3% 157 4,5%

Ricco

1996

112 0,9% 114 3,5%

per op Angiography

CONTROLE PER-OPERATOIREAngiographie per-op

Anesthésia

STROKE + DEATH +MI 30ème jour

GA 4,8 %

LA 4.5 %

Quality of life (1 month)

intervention time

ICU stay

hospital stay

3526 patients

NO différence

Héparine reversal

no major differrence between tecnics but eversion or systematic patch better than direct suture

No proof for shunting :never ,sometimes or always

Local or geneneral anesthesia are equivalent

Heparine reversal have no impact on stroke or MI risk

What about CAS ?

NEVER FOR SYMPTOMATIC PATIENT:Eva 3s , space , icss , crest:Risk x 3 comparing with CEA

Not for old > 80 years

Anatomy suitable for CAS

CAS vs CEA symptomatic stenose mortality or sroke at 30 days

Registres prospectifs NTCMM

Hobson (Crest) 99 12%2004

Stanziali (Pittsburgh) 87

9,2%2005

Gray (Capture) 594 7,9%2006

CAS RISK >80 YEARS

CAS and asymptomatic > 60%

Equivallence with CEA in crest

More than 100 CAS experience to get skills

Answer with ACST 2 study: work in progres

Progres in CAS

8F Transcervical Arterial Sheath 8F Venous Return Sheath

Large bore flow reversal circuit Flow controller with stop, HI and LO flow

Personal activity

CEA CAS

2010 88 20

2011 102 26

2012 86 43