Carotid Vascular Disease: Treatment options using surgery and interventional radiology Emily Borod MS3 Carotid Vascular Disease Stroke is 3rd leading cause of death in US (behind heart disease and cancer) Mortality from acute event is 20% 50% of patients are alive after 5 years 4% of survivors require long-term skilled nursing care 25% of survivors will have a second neurologic event Signs/symptoms of carotid vascular disease TIA (Transient Ischemic Attacks): focal neurologic defects with resolution of symptoms within 24 hours RIND (Reversible Ischemic Neurologic Deficit): transient neurologic defects lasting 24-72 hrs Amaurosis fugax: temporary blindness in one eye, frequently described as “curtain coming down” due to microemboli in retina CVA (Cerebrovascular accident): neurologic deficit with permanent brain damage Evaluating carotid disease Duplex Doppler ultrasonography Carotid Doppler ultrasonography Magnetic resonance angiography (MRA) Carotid angiography (gold standard) Sensitivity/specificity of noninvasive tests to predict stenoses >70% is 83-86%/89-94% Duplex Doppler ultrasonography MRA of carotid stenosis Carotid angiography Treatment options Medical treatment (not as effective for more advanced disease) Carotid endarterectomy (CEA) Nonsurgical carotid revascularization using angioplasty and stenting Treatment recommended for: – Asymptomatic pts with >60% stenosis – Symptomatic pts with >50% stenosis Carotid endarterectomy Performed through neck incision, usually along sternocleidomastoid muscle Proximal and distal control of artery is obtained While patient is heparinized, internal and external carotid arteries are clamped Longitudinal arteriotomy is performed, carotid plaque is removed, and vessel is closed over a patch Complications of carotid endarterectomy (perioperative mortality <0.5-3.0%, related level of expertise of surgeons) Cardiac events Bleeding Postoperative stroke Infection Hyperperfusion Parotitis syndrome Re-stenosis Nerve injury Postoperative cardiac events Appropriate cardiac work-up is essential Because these patients have atherosclerotic disease in the carotids, it must be assumed that they have atherosclerotic disease elsewhere Exercise stress testing, dobutamine echocardiography, dipyridamole imaging, or coronary catherization should be used Postoperative stroke Factors that contribute to postoperative stroke: – Plaque emboli – Platelet aggregates – Improper flushing – Poor cerebral protection – Relative hypotension Hyperperfusion syndrome Cerebral hyperperfusion is the leading cause of intracerebral hemorrhage and seizures during the first two weeks following CEA Causes changes in low-flow carotid vascular bed Small vessels compensate by dilating, then cannot re-constrict properly and therefore cannot protect vascular bed Nerve injury Nerves at risk for injury during CEA include: – Vagus nerve – Recurrent laryngeal nerve – Facial nerve – Glossopharyngeal nerve – Hypoglossal nerve – Branches of trigeminal nerve Re-stenosis Re-stenosis following CEA occurs in 20% of patients overall, and 2.6-10% at 5 years Re-stenosis within 6 months is more common when smooth muscle cells are abundant in lesion and is less common when lesions are rich in lymphocytes and macrophages Late re-stenosis results from progression of atherosclerotic disease Carotid endarterectomy Predictors of mortality following CEA Increased age Male sex (relative risk 1.58) Diabetes (RR 1.48) Systemic hypertension (RR 1.31) Smoking (RR 1.13) Predictors of recurrence following CEA Elevated cholesterol Systemic hypertension (RR 1.42) Smoking (RR 1.47) Nonsurgical carotid revascularization Percutaneous catheterization techniques have led to carotid angioplasty and stent placement Less invasive (performed with local anesthesia and sedation) Less likely to precipitate cardiac events Technique can also be used to repair stenosis that is more cephalad Technique used in nonsurgical carotid repair Catheter with umbrella tip is inserted in stenotic carotid via femoral artery Balloon is inflated to dilate artery Stent is placed in artery to maintain patency Filters are used to capture embolic particles Examples of stents used in carotid revascularization Filters used in carotid repair Pre- and post-stenting angiography Risks of nonsurgical vascular repair Plaques may be dislodged during procedure leading to neurologic events Re-stenosis is common in long term follow-up (15%) and may be difficult to treat surgically Dissection has been shown to occur in 5% of patients following stenting More studies comparing CEA to nonsurgical repair must be completed CEA vs stenting Several studies have been carried out or are in progress to compare CEA and repair of carotid artery disease using interventional radiology Because of the potentially significant and lasting damage from a stroke and the relative success of CEA, studies comparing the two treatment options have been somewhat slow to be carried out Most of the early studies compare the two techniques in specific patient groups (i.e. elderly patients or poor surgical candidates) WALLSTENT trial 219 patients with symptomatic stenosis Carotid arteries were 60-90% occluded Patients were randomly assigned to receive CEA or angioplasty and stenting (without protective filter device) 1-yr follow-up showed significantly higher rate of post-procedure stroke with angioplasty and stenting group compared to CEA group (12.2 vs 3.6%) SAPPHIRE study CEA vs carotid stenting with protective filter device 334 patients with concurrent conditions that made them poor surgical candidates Symptomatic carotid stenosis of 50% or asymptomatic stenosis of 80% Primary end-point: major cardiovascular event within one year (death, stroke, MI) Results of SAPPHIRE study Major cardiovascular events within one year were more common in CEA group than in angioplasty and stenting group (20.1% compared to 12.2%) Carotid revascularization was repeated within one year in fewer patients with stents than in patients who underwent CEA (0.6% and 4.3%, p=.04) Stenting vs CEA in elderly patients Retrospective study of pts 75 years old who had been treated for carotid stenosis 53 pts who had undergone stenting between June 2001 and April 2004 were compared to 110 pts who had undergone CEA between January 1997 and December 2001 Primary outcome was MI or major, minor, or fatal stroke within one month of treatment Results of CEA vs stenting in elderly patients Incidence of major or minor stroke within 30 days of treatment was significantly higher in stenting than in CEA group (11.3% to 1.8%, P<0.05) Incidence of major stroke within 30 days was similar in the two groups, but incidence of minor strokes was higher in stenting group (7.5% vs 0%, P<0.05) Protective embolic filter devices were used in this trial CAVATAS trial 504 pts with carotid stenosis were randomly assigned to CEA or angioplasty and stenting Results showed similar major risks and effectiveness of the two treatment options Outcomes following surgery were worse than outcomes reported in major trials evaluating carotid surgery, supporting the fact that there is a great deal of variability in outcome depending on surgeon expertise Conclusion Carotid vascular disease is prevalent in the US and results in significant mortality and morbidity when untreated Results of trials comparing the invasive treatment options are ongoing and have shown somewhat conflicting results Studies support the use of angioplasty and stenting in certain patient populations Conclusion Patients with carotid stenosis who are likely to benefit more from carotid angioplasty and stenting than from CEA include pts with significant comorbidities that make them poor surgical candidates Elderly pts may be at higher risk of having a minor stroke within 30 days following stenting than CEA The use of protective embolic filters is important in the outcome following angioplasty and stenting Conclusion Stenting is a promising option for treating carotid stenosis in patients who are high-risk surgical candidates More studies comparing the revascularization procedures are necessary before treatment recommendations can be refined Attention to long-term results of stenting should also be compared to long-term CEA results References Alhaddad, I.A.; Carotid Artery Surgery vs. Stent: A Cardiovascular Perspective; Catheterization and Cardiovascular Interventions; 63:377-384 (2004). Brott, T.G., et al; Carotid Revascularization for Prevention of Stroke: Carotid Endarterectomy and Carotid Artery Stenting; Mayo Clinic Proceedings, 79(9), 1197-1208 (2004). Eskandari, M.K., et al; Does Carotid Stenting Measure Up to Endarterectomy? A Vascular Surgeon’s Experience; Archives of Surgery, Vol.139, pp. 734-738 (2004). Greelish, J.P., et al; Nonsurgical carotid revascularization; UpToDate, www.uptodate.com. Greelish, J.P., et al; Carotid endarterectomy: Preoperative evaluation, surgical technique, and complications; UpToDate, www.uptodate.com. References Phatouros, C.C., et al; Carotid Artery Stent Placement for Atherosclerotic Disease: Rationale, Technique, and Current Status; Radiology; Oct 2000. Kastrup, A., et al; Comparison of angioplasty and stenting with cerebral protection versus endarterectomy for treatment of internal carotid artery stenosis in elderly patients; Journal of Vascular Surgery, Nov. 2004. Kirsch, E.C., et al; Carotid Arterial Stent Placement: Results and Follow-up in 53 Patients; Radiology; Sept. 2001. Yadav, J.S., et al; Protected Carotid-Artery Stenting versus Endarterectomy in High-Risk Patients; The New England Journal of Medicine, 351:15 (2004).
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