Disclosures Minor Stroke Effects Long-Term None Survival after - - PowerPoint PPT Presentation

4/4/2014 1

Minor Stroke Effects Long-Term Survival after CAS/CEA

Joseph H. Rapp, MD Chief, Vascular Surgery Service SFVAMC Professor of Surgery, UCSF

Disclosures

• None

CREST DATA

• Combined end point of Stroke, Death and MI

equivalent

– Stroke with CAS, MI with CEA

• Published F/U article showing, as predicted,

decreased survival after peri-procedural MI

• Over 4 yrs: 3.4 fold increase mortality after MI

(EKG); 3.7 fold increase mortality post procedure Bio Marker rise

Late Mortality post Peri-procedural MI (CREST)

1 yr 4 yr 42 MI’s 6 (14.3%) 8 (19.1%) 20 non-STEMI 1 (5.0%) 4 (25%) 2440 No MI 44 (2.2%) 111 (6.7%)

Blackshear Circ 2011

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Late Mortality post Stroke (CREST)

Stroke Definition

I can tell if a patient has had a peri-procedural Stroke.

Y e s . W h e n t h e . . . N

• .

M a y b e , b u t i t . . .

0% 90% 10%

• A. Yes. When there is a change, the patient

knows, the family knows, I know.

• B. No.
• C. Maybe, but it is often quite subtle

Stroke Definition 2

There are NIH consensus guidelines on what constitutes a Major and a Minor Stroke.

Y e s . T h e y a r e . . . N

• .

T h e N e u r

• .

. . N

• t

s u r e .

65% 13% 22%

• A. Yes. They are commonly used to grade

deficits after stroke (Fischer, Stroke 2010)

• B. No. The Neurologist can’t agree on

anything

• C. Not sure.

Late Mortality post Peri-procedural Stroke (CREST)

• 300 “potential” events
• 46 deemed TIA or

amaurosis fugax

• 81 adjudicated as stroke
• 69 were peri-procedural

– 56 Minor – 13 Major

Hill Circ 2012

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Late Mortality post Stroke (CREST)

1 yr 4 yr Stroke (any) (69) 17% 21.2% No Stroke (2272) 3% 11.6%

Blackshear Circ 2012

Late Mortality post peri-procedural Stroke or MI (VSGNE)

1yr 5 yr 81 MI’s 16% 44% 63 Strokes 23%

P<0.001

40% 8171 Neither 4% 20%

Simons JVS 2013

Late Mortality post Peri-procedural Stroke or TIA (Bologna)

5 yr Stroke 29 68.2% TIA 38 78.4% No Event 1323 97%

Pini JVS 2014

Survival post TIA (Dutch)

Wijk Lancet 2005

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Why is Stroke a marker for poor survival? Late Outcomes after Carotid Intervention

• Peri-procedural MI is bad and Stoke is worse
• Minor Stroke and even TIA substantially

reduce long term survival

• Unknown role for silent ischemia (DW-MRI)
• A new era where we recognize that peri-

procedural outcomes are only part of the cost

• f intervention.

Brain uniquely susceptible to emboli

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What is a “Minor” Stroke?

CREST showed a poor long-term

• utcome for peri-op MI

Late Mortality post Peri-procedural Stroke or TIA (Bologna)

5 yr 29 Strokes 68.2% 38 TIA’s 78.4% 1323 Neither 97%