Carotid surgery 2014

Sean TierneyDean of Professional Development & Practice RCSI

Consultant Vascular Surgeon

Carotid diseaseCarotid disease

Case presentationCase presentation

History• 62 year old • 6 hours ago

• Transient (R) arm weakness

• Fully resolved within 2 hrs

• No sequelae

PMHx• Cigs 20 pack year

• No meds

Brain attack – the urgencyBrain attack – the urgency

Copyright ©2004 BMJ Publishing Group Ltd.

Coull, A J et al. BMJ 2004;328:326

7% @ 1 week

10% @ 1 month

≅15% @ 1 month

Case presentationCase presentation

Physical examination

Systematic

• Neurological

• Cardiovascular

Head to toe

Relevant positive and negative findings

Case presentationCase presentation

Differential diagnosis

History

Differential diagnosis

Examination

Review differential diagnosis

Investigation

Treat

Review differential diagnosis

Evaluate response

Key questionsKey questions

• Is there a stroke?• Is it haemorrhagic or

ischaemic?• Where might the source

be?

InvestigationsInvestigations

• Is there a stroke?• Is it haemorrhagic or

ischaemic?• Where might the source

be?

• Clinical

• CT Brain• MRI• DW-MRI (Timing)

InvestigationsInvestigations

• Is there a stroke?• Is it haemorrhagic or

ischaemic?• Where might the source

be?

• CT Brain• MRI

InvestigationsInvestigations

• Is there a stroke?• Is it haemorrhagic or

ischaemic?• Where might the source

be?

• Duplex carotids– MRA– CTA– (angiography)

• Echocardiography– TTE– TOE

• Holter

DuplexDuplex

• Degree of stenosis • ? criteria• ? reliability

• Nature of plaque• Position of

bifurcation

Left ICA80-90% stenosis

Left ICA80-90% stenosis

Current recommendationsCurrent recommendations

Chappell et al Radiology 2009

Contrast enhanced magnetic resonance angiography (CEMRA)

• offered the best sensitivity and specificity

• limited by cost & accessibility

Non-invasive imaging• accuracy is highest in patients with 70–99% stenoses

and less with 50–69% stenoses

?double scanning

InvestigationsInvestigations

• Is there a stroke?• Is it haemorrhagic or

ischaemic?• Where might the source

be?• Is the patient a suitable

candidate for surgery?

• Co-morbidity• Consent

The ContextThe Context

Naylor. The Surgeon 2009

Evidence based medicineEvidence based medicine

• I Meta-analysis & systematic reviews

• II Randomised Control Trial

• III Case control (non-randomised)• IV Retrospective, cross-sectional

• V Expert opinion, descriptive studies

FFact

OOpinion

GGossip

Sackett et al. 1996 Br Med J

ECST outcomesECST outcomes

Ipsilateral major stroke + operative major stroke or death ECST

OutcomeOutcome

High Moderate LowSurgery 7.50% 12.70% 12.70%Control 13.70% 17.90% 11.40%OR (95% CI) 0.48 (0.33-0.70) 0.69 (0.51-0.94) 1.23 (1.00-1.51)RRR 48% 27% -20%NNT 15 21 45

Death/disabling stroke (2-6 years follow up)

Cina C et al. Cochrane Database of Systematic Reviews 1999. (accessed 2010)

ConclusionConclusion

Surgery reduces the risk of stroke in those with moderate or high grade carotid stenosis provided 30 day stroke and death rate <6%

Symptomatic disease

Cina C, Clase C, Haynes RB. Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database of Systematic Reviews 1999, Issue 3. Art. No.: CD001081. DOI: 10.1002/14651858.CD001081

ChoicesChoices

ChoicesChoices

Carotid endarterectomyCarotid endarterectomy

www.acssurgery.com Stroke and Transient Ischemic Attack. TS Maldonado, TS Riles

Carotid endarterectomyCarotid endarterectomy

www.acssurgery.com Stroke and Transient Ischemic Attack. TS Maldonado, TS Riles

Carotid endarterectomyCarotid endarterectomy

www.acssurgery.com Stroke and Transient Ischemic Attack. TS Maldonado, TS Riles

Technical concernsTechnical concerns

• Anaesthesia– No proven difference

• Eversion vs standard– No proven benefit

• Shunting/monitoring– No proven difference

• Patching– Less recurrence

Postoperative carePostoperative care

• Neurological status

• Blood Pressure

• Wound issues

Lipsett et al J Vasc Surg 1994

Neurological statusNeurological status

• Alert

• Speech

• Limb movement

• Premorbid state

Concerns

• Stroke

• Cerebral oedema

Blood pressureBlood pressure

• + 10% preop blood pressure

• Intravenous agents may be required

• Hypoperfusion• Hyperperfusion

syndrome

Wound problemsWound problems

• Haematoma

• Usually early

• + Swelling

• Distended veins

• Stridor

• Surgical review

Day 1+Day 1+

• Diet

• Mobilise

• Home by day 3-5

• ? Day 2

PostoperativelyPostoperatively

• Risk Factor modification

• Aspirin

• Statin

• BP control

Case #2Case #2

History

• 64 year old

• Hypertension

• Hyperchlesterolaemia• “Routine carotid scan”

PMHx• Cigs 20/day

• Thiazide, ACE inhibitor, Statin

• Coronary angioplasty 4 years previously

Examination• No bruit• I II nil added

InvestigationsInvestigations

70-80% stenosis70-80% stenosis LV hypertrophyEF 45%

LV hypertrophyEF 45%

EvidenceEvidence

MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group.The Lancet 2004

ConclusionConclusion I

Chambers BR, You RX, Donnan GA The Cochrane Library, 2004.

Time moves on…Time moves on…

Time marches on…Time marches on…

Naylor The Surgeon 8(2010);79–86.

Better medical therapyBetter medical therapy

Abbott Stroke 2009

Better medical therapyBetter medical therapy

Abbott Stroke 2009

… BMT is now three to eight times more cost-effective than CEA/CAS (in terms of stroke prevention)…

… BMT is now three to eight times more cost-effective than CEA/CAS (in terms of stroke prevention)…

… … and better…and better…

The average annual event rates on medical treatment were 0.34% (95% CI, 0.01 to 1.87) for any ipsilateral ischemic stroke …

The average annual event rates on medical treatment were 0.34% (95% CI, 0.01 to 1.87) for any ipsilateral ischemic stroke …

Marquardt Stroke 2010

Patient selectionPatient selection

Plaque morphologyEnd organ effects

Patient selectionPatient selection

Plaque morphologyPlaque activity

Plaque activityPlaque activity

• 482 patients (asymptomatic carotid stenosis >70%), 467 had TCD• +ve TCD (emboli 77/467)

• increase in risk in +ve at 2 years• ipsilateral stroke and transient ischaemic attack from baseline 2·54 (95% CI 1·20–5·36; p=0·015). •ipsilateral stroke alone 5·57 (1·61–19·32; p=0·007). •absolute annual risk of ipsilateral stroke was 3·62% in patients with embolic signals and 0·70% in those without.

Asymptomatic carotid stenosisAsymptomatic carotid stenosis

??

Carotid stenting4

Carotid angioplastyCarotid angioplasty

Carotid stentingCarotid stenting

44

Carotid stentingCarotid stenting

44

• 13 randomised trials

• 7477 patients

• October 11, 2010

Bangalore et al Arch Neurol 2010

CAS trialsCAS trials

Bangalore et al Arch Neurol 2010

Procedure outcomeProcedure outcome

Bangalore et al Arch Neurol 2010

Periprocedural death, stroke or MI

Long term resultsLong term results

Periprocedural death, stroke or ipsilateral stroke on f/upBangalore et al Arch Neurol 2010

SummarySummary

Carotid artery stenting was associated with an

•↑ periprocedural outcomes of death, MI, or stroke (odds ratio = 1.31; 95% confidence interval, 1.08-1.59)•↑ 65% and 67% in death or stroke and any stroke, respectively•↓55% and 85% reductions in the risk of MI and cranial nerve injury, respectively, when compared with CEA.

Bangalore et al Arch Neurol 2010

SummarySummary

Similarly, CAS was associated with (RR vs CEA) in longer term follow-up:

– ↑19% periprocedural death or – ↑ 38% stroke and ipsilateral stroke thereafter, – ↑ 24% death or any stroke, – ↑ 48% any stroke

Bangalore et al Arch Neurol 2010

Carotid stentingCarotid stenting

• CAS was associated with an increased risk of both periprocedural and intermediate to long-term outcomes, but with a reduction in periprocedural MI and cranial nerve injury. Strategies are urgently needed to identify patients who are best served by CAS vs CEA.

• CAS was associated with an increased risk of both periprocedural and intermediate to long-term outcomes, but with a reduction in periprocedural MI and cranial nerve injury. Strategies are urgently needed to identify patients who are best served by CAS vs CEA.

Bangalore et al Arch Neurol 2010

Carotid stenting vs endarterectomyCarotid stenting vs endarterectomy

Ederle J, Featherstone R, Brown MM. Percutaneous transluminal angioplasty and stenting for carotid artery stenosis. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD000515. DOI: 10.1002/14651858.CD000515.pub3

5 Timing

IntervalsIntervals

Copyright ©2004 BMJ Publishing Group Ltd.

Coull, A J et al. BMJ 2004;328:326

7% @ 1 week

10% @ 1 month

≅15% @ 1 month

55

EndarterectomyEndarterectomy

• Carotid endarterectomy trialists collaboration (CETC)

• Reanalysed all carotid RCT data

• Standardised measurements

• Rothwell et al Lancet 2004

DelayDelay

• No of strokes saved per 1000 CEA for symptomatic carotid stenosis (CETC re-analysis)

Rothwell et al 2004

Who is at risk..?Who is at risk..?

Naylor. The Surgeon 2010

Best practiceBest practice

Patients with TIA/minor stroke should be • seen as soon as possible in dedicated (daily)

open access clinics that offer single visit imaging.

• all patients should start taking their risk factor medications as soon as possible (Express study)

• Patients with a 50–99% ipsilateral ICA stenosis should be admitted to the Vascular Unit for corroborative (duplex) imaging and expedited surgery.

Naylor. The Surgeon 2010

RealityReality

Naylor. The Surgeon 2010

RealityReality

Naylor. The Surgeon 2010

UK Carotid Endarterectomy Audit (2009)… only 20% of patients underwent surgery within 14 days of symptom onset.

• Appropriate treatment• Correct operation• Right patient• Right time• Technical accuracy• Postoperative care

• Appropriate treatment• Correct operation• Right patient• Right time• Technical accuracy• Postoperative care

www.perfuse.netwww.perfuse.net

@theseant@theseant

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