Carotid Stenosis carotid endarterectomy vs angioplasty with stent

					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).