Endovascular Management of Intracranial and Extracranial Atherosclerosis Rishi Gupta, MD Associate Professor of Neurology, Neurosurgery, and Radiology Emory University School of Medicine Director,Multi-Center Acute Stroke Network Marcus Stroke and Neuroscience Center Grady Memorial Hospital
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Endovascular Management of Intracranial and Extracranial Atherosclerosis Rishi Gupta, MD Associate Professor of Neurology, Neurosurgery, and Radiology.
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Endovascular Management of Intracranial and Extracranial
Atherosclerosis
Rishi Gupta, MDAssociate Professor of Neurology, Neurosurgery, and Radiology
Emory University School of MedicineDirector,Multi-Center Acute Stroke Network
Marcus Stroke and Neuroscience CenterGrady Memorial Hospital
Extracranial Carotid Artery Disease
700,000 Strokes annually in the US 1
Extracranial carotid artery disease accounts for 10-15 % of Ischemic Cerebral Infarctions 2
Causes cognitive impairment 3
11Ovbiagele et al. , Stroke 20032 2 Whisnant 19953 3 Rao et al., Stroke 1999Rao et al., Stroke 1999
Natural History of Carotid Disease
Strongest predictors of future events 1
Prior ipsilateral hemispheric symptoms Degree of stenosis
Other predictors of future events Unstable plaque 2 (ulceration, intraplaque
Randomized Study-All Patients 30 Days Events (N= 156 vs 151)
3.8%
5.3%
2.6%
7.3%
0.6%
2.0%
5.8%
12.6%
0%
2%
4%
6%
8%
10%
12%
14%
Stroke MI Death Stroke/MI/D
StentingCEA
P=0.047
Randomized trial Randomized trial 1:1 CEA vs CAS1:1 CEA vs CAS Designed to prove non-inferiorityDesigned to prove non-inferiority Symptomatic patients with Symptomatic patients with 60% 60% 524 patients enrolled524 patients enrolled Stopped prematurely due to safety and Stopped prematurely due to safety and
futilityfutility
EVA 3S
EVA 3S - IssuesEVA 3S - Issues
Operator experienceOperator experience ::
– 12 carotid stents does not require 014 experience12 carotid stents does not require 014 experience– 35 supraaortic stents (of which 5 carotids) or35 supraaortic stents (of which 5 carotids) or– performance of stenting under supervision by proctor who performance of stenting under supervision by proctor who
fullfills above criteriafullfills above criteria
No requirement for :No requirement for : - dual antiplatelet therapy (15% without)- dual antiplatelet therapy (15% without) - uniform stent/protection device - uniform stent/protection device - use of protection device (10% without)- use of protection device (10% without)
SPACE
-Randomized trial Randomized trial
-1:1 CEA vs CAS-1:1 CEA vs CAS
- Designed to prove non-inferiority- Designed to prove non-inferiority
- Symptomatic patients with - Symptomatic patients with 50% (NASCET) 50% (NASCET)
- 1200 patients enrolled- 1200 patients enrolled
-Stopped prematurely due to lack of funding-Stopped prematurely due to lack of funding
SX ICA WITH LARGE ULCERATION SX ICA WITH LARGE ULCERATION TREATED WITH EMBOLI PREVENTION TREATED WITH EMBOLI PREVENTION FILTERFILTER
Filter
PRE FILTER POST
EMBOLIZEDPLAQUE
EMBOLIZEDPLAQUE
CREST
Randomized controlled study of 2502 patients with conventional risk
1:1 randomization to CAS vs. CEA Included symptomatic and
Asymptomatic patients Primary endpoint of any stroke, death
or MI Rigorous vetting process with a lead in
phase for investigators and prior experience with a pre-defined 6% complication rate in the past
Peri-procedural Stroke and MI
CAS vs. CEA
Hazard Ratio 95% CIP-Value
Stroke
4.14.1 vs.
2.32.3%
HR = 1.79; 95% CI: 1.14-2.82
0.01
MI1.11.1 vs.
2.32.3%
HR = 0.50; 95% CI: 0.26-0.94
0.03
Primary Endpoint ≤ 4 years(any stroke, MI, or death within peri-procedural period
plus ipsilateral stroke thereafter)
CAS vs. CEA
Hazard Ratio, 95% CIP-
Value
7.27.2 vs.
6.86.8%%HR = 1.11; 95% CI:
0.81-1.510.51
0
1
2
3
4
40 50 60 70 80 90
Haz
ard
Ratio
Age (Years)
Pinteraction = 0.020
CEA Superior
CAS Superior
Primary outcome – 4 year
Study # Patients
Tutor Allowed
Stent Type Dual Anti-platelet
EPD Use 30 day stroke
CAVATAS 504 No Angioplasty Aspirin 0% 8%
EVA 3S 527 Yes Multiple 15% not on dual anti-platelets
91% 8.8%
SPACE 1200 Yes Multiple Mandated 27% 6.5%
ICSS 1710 Yes Multiple Recommended 72% 6.3%
CREST 2502 No Acculink Mandated Mandated 4.1%
SAPPHIRE 334 No Precise Mandated Mandated 3.6%
Summary of Randomized CAS Studies
Summary of Carotid Treatment
Carotid revascularization recommended for patients with moderate to severe stenosis:
- If Sx and survival > 2 years - If ASx and survival > 5 years
CEA and CAS are both options available for revascularization Multidisciplinary approach with surgery, endovascular specialist
and neurologist will likely yield best clinical outcome
As with ICAD, maximal medical therapy important towards reducing risk of stroke, MI long term
Conclusions
Medical management pre and post carotid revascularization may impact safety, durability of treatment
CAS will likely have a larger role in carotid revascularization after CREST.
Interest in cognitive differences between CAS and CEA, also ? if distal vs. proximal protection leads to reduced downstream emboli