Carotid Stenting MDS by sammyc2007

VIEWS: 181 PAGES: 57

									Kuwait Experience:

Carotid Artery Stenosis
Dr. Hussein Safar * Dr. Tareq Sinan **
Consultant Vascular Surgeon* Vascular Intervention Radiologist ** Mubarak AL Kabeer Hospital Kuwait

Carotid Artery Stenosis

Carotid Endarterectomy (CEA)

Carotid Stenting (CS)

Carotid Artery Stenosis
• • • • • • • Introduction Indications Stents & Devices Complications Local Experience Cases Conclusion

Carotid Artery Stenosis
• • • • • • • Introduction Indications Stents & Devices Complications Local Experience Cases Conclusion

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Introduction
• 1953 CEA was described by DeBakey
ANN Surg 1959,149

• 1970’s Angioplasty to peripheral arteries started. • 1977 1st carotid angioplasty on animal. • 1979 1st carotid angioplasty for female with Fibromuscular dysplasia.
Mathias K, Angio 1981, & Fortschr Med 1977

• 1992 Angioplasty of carotid was avoided since Brown due to the risk of embolic stroke ~ 1-2 %
[Neurol Res 1992 & J Neurol NeuroSurg Psych. 1993]

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Introduction
Risk of embolic stroke  Carotid Surgery or Stenting

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Introduction
• Embolization CS > CEA
[Jorden WD, Cardiovasc. Surg 1999 (7)]

• Theron was 1st to use cerebral protection in 1987 to reduce embolic events
[Theron JG, Radiology, 1996 (201)]

Kuwait Experience: Carotid Artery Stenosis

Rx

Carotid Artery Stenosis

Carotid Endarterectomy (CEA)

Kuwait Experience: Carotid Artery Stenosis

Rx

Carotid Artery Stenosis

Carotid Stenting (CS)

Carotid Artery Stenosis
• • • • • • • Introduction Indications Stents & Devices Complications Local Experience Cases Conclusion

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Indications for Surgery (CEA) Symptomatic or Asymptomatic carotid artery stenosis of > 70 %

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Carotid Endarterectomy (Randomized Controlled Trials) Symptomatic NASCET & ECST
[NEJM, 1991 (325) & Lancet, 1991 (337)]

Asymptomatic ACAS & ACST
[Jama, 1995 (273) & Lancet, 2004 (363)]


superior to medical treatment alone in preventing stroke

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Indications for Stenting (CS) Hostile Carotid [Re-do & Radiated Neck] High risk patient [severe co-morbid condition]

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Carotid Stenting
(Randomized Controlled Trials)
Done CAVATAS SAPPHIRE CaRESS (I) SPACE EVA-3S


No statistically difference CEA & CS in preventing stroke

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Carotid Stenting
(Randomized Controlled Trials) CAVATAS
(Carotid And Vertebral Artery Trans-luminal Angioplasty Study)

 

504pt CEA=253 & CS=251

No difference CEA & CS [stroke and death rate, both 6%]
[Br J Surg 1999]

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Carotid Stenting
(Randomized Controlled Trials) SAPPHIRE
(Stenting & Angioplasty with Protection in Patients at High Risk for Endarterectomy)

 

334pt CEA=167 & CS=167
No difference CEA & CS
[NEJS 2004]

Kuwait Experience: Carotid Artery Stenosis

Carotid StentingCarotid Revascularization Using Endarterectomy or Stenting Systems (CaRESS) phase I clinical trial: 1-year results .
sympt >50% stenosis or asympt >75% stenosis

397 pts (254 CEA & 143 CAS) 32% symptomatic & 68% asymptomatic. no significant differences in combined death/stroke (3.6% CEA vs 2.1% CAS) 30 days (13.6% CEA vs 10.0% CAS) 1 year Restenosis (3.6% CEA vs 6.3% CAS),
30-day & 1-year risk of death, stroke, or MI with CAS is equivalent to that with CEA in symptomatic and asymptomatic patients with carotid stenosis.
CARESS: Phase I Clinical Trial J Endovasc Ther. 2003 Nov-Dec; 10(6): 1021-1030. . CaRESS Steering Committee‫ ـ‬J Vasc Surg .2005, Aug;42(2):213-9.

Kuwait Experience: Carotid Artery Stenosis

30 day results from the SPACE trial of stentprotected angioplasty vs. CEA in symptomatic patients: a randomised non-inferiority trial.
1200 sympt pts. CS n=605 & CEA n=595. death or stroke (30 days)

6.84% CS vs. 6.34% CEA
SPACE failed to prove non-inferiority of carotid-artery stenting compared with carotid endarterectomy for the periprocedural complication rate. The results of this trial do not justify the widespread use in the short-term of carotid-artery stenting for treatment of carotid-artery stenosis
Lancet. 2006 Oct 7;368(9543):1239-47...SPACE Collaborative Group.

Kuwait Experience: Carotid Artery Stenosis

Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. EVA-3S
527 pt sympt. stenosis of at least 60%.

(30-day) any stroke or death 3.9% = CEA (C.I 95%, 2.0 to 7.2) Vs. 9.6% CS (95% CI, 6.4 to 14.0);
Relative risk of any stroke or death after CS vs. CEA = 2.5 (95% CI, 1.2 to 5.1).

(30-day) disabling stroke or death 1.5% CEA (95% CI, 0.5 to 4.2) Vs. 3.4% CS (95% CI, 1.7 to 6.7);
Relative risk = 2.2 (95% CI, 0.7 to 7.2).

(6-months) any stroke or death 6.1% CEA Vs. 11.7% CS (P=0.02)



CS=more major local complications CEA= more systemic complications death and stroke (1 & 6 months) lower with CEA than with CS . (no statistical difference)
N Engl J Med. 2006 Oct 19;355(16):1660-71. EVA-3S Investigators

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Carotid Stenting
(Randomized Controlled Trials)
On going CaRESS CREST CS “superior or same as CEA in preventing stroke” 



Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Carotid Stenting
(Randomized Controlled Trials)
On going

CaRESS
(carotid revascularization with endarterectomy or stenting system) symptomatic (excluded by CREST) & asymptomatic. CS “superior or same as CEA in preventing stroke” 
Roubin GS J Endovascu Thera 2001



Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Carotid Stenting
(Randomized Controlled Trials)
On going

CREST
(carotid revascularization endarterectomy vs. stent trail) High grade symptomatic (Needs 2500 pt). Primary out comes 1) death, Stroke & MI @30d. 2) Stroke @4 y.

CS “superior or same as CEA in preventing stroke” 
Roubin GS J Endovascu Thera 2001



Kuwait Experience: Carotid Artery Stenosis

Carotid stenting with distal protection in high surgical risk patients: the BEACH trial 30 day results.
Non-Randomized New Orleans, USA. 747 pt with high surgical risk for CEA sympt (>50% stenosis) asymp (>80% stenosis) high surgical risk patients. 30 days complications =5.8% (all death = 1.5%, all stroke = 4.4%, and MI = 1.0%).  The 30-day safety of this stent and distal emboli protection system is encouraging and compares favorably with other carotid stent trials in high surgical risk patients.
Catheter Cardiovasc Interv. 2006 Apr;67(4):503-12. BEACH Trial Investigators.

Carotid Artery Stenosis
• • • • • • • Introduction Indications Stents & Devices Complications Local Experience Cases Conclusion

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Stents
Types (Self Expanding ) 1. Wallstent (Boston Scientific Corp. USA) 2. Nitinol (smart stent from J&J)

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Protective Device

EVA-3S Trail

“Carotid angioplasty and stenting with and without cerebral protection: clinical alert from Endarterectomy vs. angioplasty In patients with symptomatic severe carotid stenosis (EVA-3S) trail”
Mas JL et al – Stroke 2004

Randomized trail for CS with and without protective device  The rate of stroke without protection was 3.9 times higher than CS with protection.

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Protective Device Types Filter Occlusive balloon

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
AngioGuard

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
EPI filter wire

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Parodi

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
New Parodi From Gore Co. “ Nuro-Protection System” NPS It is with venous filter

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Protective Device Types Occlusive balloon Filter

Carotid Artery Stenosis
• • • • • • • Introduction Indications Stents & Devices Complications Local Experience Cases Conclusion

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Complications of CEA
 Peri-operative major stroke & death rate.  Symptomatic ~ 5.8 %
[NEJM, 1991 (325)]

 Asymptomatic ~ 2.8 % 

[Jama, 1995 (273)]

Restenosis ~ 36%
[Healy DA J Vasc Surg 1989 ]

Cranial nerve palsies ~ 27%
[Am Heart Assoc 1996]


  

Intracranial haemorrhage ~ 1%
[Pomposelli FB J Vasc Surg 1988]

Alteration of BP ~ 66% Infections ~ rare Haematoma & Bleedings ~ 3%

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Complications of CS
 Major (disabling) stroke & death rate.  without protection ~ 11 %  with protection ~ 2-6 %  Re-stenosis ~ 18 %  Intracranial haemorrhage ~ 5%
[Qureshi AL, Stroke 2000]

 Haematoma & Bleedings ~ 1 %
[Castriota F,JEVT-2002]

 Rupture artery ~ 1 %
[Broadbent LP et al AINR Am J Neuroradiol 2003]

 Hypotension & Bradycardia ~ 7 %
[Mlekusch W et al J Endovac Ther 2003]

 Hyperperfusion syndrome ~ 3 %
[Coutts SB et al - Neurosurgery 2003]

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Major stroke & death rate.

Carotid Surgery

Carotid Stenting
(with protection)

6%

6%

Carotid Artery Stenosis
• • • • • • • Introduction Indications Stents & Devices Complications Local Experience Cases Conclusion

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Disease
Local Experience
• • • • • • • Type of Study: Period: Era: N of Carotids: Treatment: Primary End-point: Secondary End-point:
Retrospective
1996-2007 (CS started in April, 2004) CEA & CS

115

59=CEA & 52=CS
All major Stroke & Death rate Other complications

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Disease
CEA=59

Local Experience
Total=115

Carotid angio.=61 CS √=52 CS Ҳ=9

Angiography Findings Difficult access (Kinking & Coiling of ICA) Total occlusion of ICA Stenosis was < 60% Severe Circumferential calcification of ICA

n/9 4 2 2 1

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Disease
Demographic
Age (mean±SD) years Male, sex Kuwaiti Diabetes Hypertension Ischaemic Heart Disease Hyperlipidaemia Smoker
Stroke Renal F. (dialysis)

CEA n/59 (%)
62±6.3 41 (69) 41 (69) 38 (64) 44 (75) 28 (47) 24 (41) 30 (51)
28 (47) 2 (3.3)

CS n/52 (%)
63±7.9 34 (65) 30 (58) 39 (75) 44 (85) 30 (58) 36 (69) 15 (29)
27 (52) 5 (10)

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Disease

Symptoms
Asymptomatic Symptomatic

CEA n/59 (%)
24 (41) 35 (59)

CS n/52 (%)
33 (63) 19 (37)

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Disease
% Stenosis CEA n/59 (%)
1 (1.6) 14 (24) 44 (75)

CS n/52 (%)
10 (19) 15 (29) 27 (52) 0 (0) 18 (35) 26 (50) 8 (15)

Duplex
60-70% 71-79% 80-99%

Angiographic
60% 70% 80% 90%

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Disease
Complications
Minor Stroke Major Stroke Death All Stroke & Death Wound Hematomas MI Cranial Nerve Injury Bradycardia Asymptomatic Re-stenosis

CEA n/59 (%)
1 (1.6) 2 (3.3) 0 3 (5.1) 9 (15) 0 2 (3.3) 0 3 (5.1)

CS n/52 (%)
0 1 (1.9) 0 1 (1.9) 0 0 0 1 (1.9) 3 (5.7)

P value
ns ns ns ns 0.003 ns ns ns ns

Carotid Artery Stenosis
• • • • • • • Introduction Indications Stents & Devices Complications Local Experience Cases Conclusion

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Case 1

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Case 2

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Case 3

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Case 4a

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Case 4b

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
Case 6

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
F/U Duplex Scan
Three month Duplex follow-up, patent stent, by Duplex [Wallstent]

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Stenosis
F/U after 2 y
Duplex Scan CT angio Angiogram

Carotid Artery Stenosis
• • • • • • • Introduction Indications Stents & Devices Complications Local Experience Cases Conclusion

Kuwait Experience: Carotid Artery Stenosis

Carotid Artery Disease
Conclusion
Our retrospective cohort of patients
(Symp. & asymp. & stenosis > 70%)

• CS is as good as CEA in preventing stroke & death • CS has more bradycardia • CS & CEA gets re-stenosis • CS without wound haemaomas or nerve injuries

Kuwait Experience: Carotid Artery Stenosis

1953

Carotid Artery Disease

Surgery

1992 Stenting

2007

CEA

CS

Carotid

Stenting Surgery
Thank You


								
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