Disclosures Your Patient Has Carotid Bulb Stenosis and a Chief - - PowerPoint PPT Presentation

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Your Patient Has Carotid Bulb Stenosis and a Tandem Intracranial Stenosis: How Do SAMMPRIS and 
Other Evidence Inform Your Treatment?

UCSF Vascular Symposium 2015

Steven W. Hetts, MD Associate Professor of Radiology Interventional Neuroradiology University of California, San Francisco

Disclosures

• Chief Medical Officer: ChemoFilter
• Scientific advisory: Medina Medical
• Consulting: Stryker Neurovascular, Silk Road Medical
• Data Safety and Monitoring Committee: DAWN trial
• Core Imaging Lab: MAPS, FRED, SURMOUNT, and ATLAS

trials

• Grant support: NIBIB, NCI, Siemens
• I will discuss off-label uses of devices (stents, balloons)
• I have borrowed liberally from my colleagues and

acknowledge their kind help: Christopher Dowd, MD, Joey English, MD, PhD, Daniel Cooke, MD, Peter Jun, MD, Van Halbach, MD, Randall Higashida, MD

Lecture Outline

• Cervical Atherosclerotic Disease
• Scope of disease
• Trials
• Practical considerations
• Intracranial Atherosclerotic Disease
• Scope of disease
• Trials
• Practical considerations
• Future directions

CREST Trial: Summary

Brott et al, NEJM 2010 363:11-23

• Composite death, stroke, and MI does not

differ between CAS and CEA in sxs and asx patients

• Paradoxically, in patients under 70 years, CAS

may be more advantageous than in patients

• ver 70 years
• Higher periprocedural stroke risk with CAS
• Higher periprocedural MI risk with CEA

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CAS: Patient Selection

• Hemodynamically Significant > 50-70%
• Failed Medical Therapy
• Clinically Symptomatic

– Stroke – TIA – Focal Neurological Signs – Amaurosis Fugax

Carotid Stenting Indications

• High Risk Surgical Patients

– Severe Coronary or Pulmonary Disease – Recent MI, Stroke

• Surgically Difficult Access

– Lesions arising off Aortic Arch – Lesions above the Mandible >C2 – All Intracranial Lesions

• Traumatic or Spontaneous Dissections

Relative Carotid Stenting Indications

• Multiple Vessel Disease

– Occlusion of Contralateral Carotid or Vertebral – Tandem Stenosis with Intracranial Lesion

• Recurrent Stenosis Post Endarterectomy
• History of Cervical Radiation
• Long Segment Lesions >4 cm
• Traumatic Carotid Pseudoaneurysms

Pre Treatment Assessment

• Complete Neurological

Assessment

• Brain MRI/CT Scan
• Anti-Platelet Medications
• Cerebral Blood Flow

Studies

• Complete Angiographic

Assessment

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Case Example

53 yo F with progressive stepwise L hemiparesis

Tandem cervical ICA and MCA stenoses

Treatment options

• Medical management
• Stent cervical ICA under conscious sedation
• Stent cervical ICA under MAC
• Stent cervical ICA under GA
• Stent cervical ICA and PTA MCA under GA
• Stent cervical ICA and stent MCA under GA
• ECA-ICA bypass
• Run the other way

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Cervical ICA stenting

Cerebral diagnostic DSA pre ICA stent Cerebral DSA pre and post ICA stent

Initially no change in HP post ICA stenting, then worsening HP

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Original DWI before ICA stenting New areas of temporal ischemia Now what would you do?

• Medical management
• ICU pressor challenge
• PTA MCA
• Stent MCA
• ECA-ICA bypass
• Run the other way
• Get more imaging

CT Perfusion

rCBV MTT

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CT Perfusion

rCBV MTT

M2 MCA severe stenosis ICAD: Scope of Disease

• 8-10% of strokes and TIAs in USA due to ICAD
• 70,000-90,000 strokes/TIAs per year
• Recurrent stroke risk 15-25% per year
• Higher ICAD rate in Black, Asian, and Hispanic

populations

Medical Therapy for ICAD

• Anticoagulation for ICAD described in 1955
• Retrospective studies suggested warfarin was

superior to ASA for ICAD stroke prevention

• WASID (2005): landmark prospective trial

comparing ASA to warfarin for recurrent stroke/TIA prevention

• WASID showed no benefit of warfarin over

ASA and increased risk of bleeding

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ECA-ICA Bypass for ICAD

• Described in 1967 to prevent stroke in

patients with symptomatic ICA or MCA stenoses

• Prospective ECIC bypass trial (NEJM 1985)

– 1377 pts randomized to bypass or medical tx – ECIC bypass no better for ICA lesions – ECIC bypass worse for severe MCA stenoses

• COSS Trial (stopped in 2010 by NIH)

– ECIC bypass for carotid occlusion patients with increased oxygen extraction fraction by PET

PTA and Stenting for ICAD

• WASID trial suggested that best medical therapy

for ICAD still had high risk for recurrent stroke

• Reasonable to research PTA and stenting as well

as new medications for ICAD

• Off label use of coronary PTA balloons since

1980s

• Off label use of coronary stents since 1990s
• SAMMPRIS Trial

– Randomized symptomatic ICAD patients to medical therapy (ASA/clopidogrel) or stent designed for ICAD plus ASA/clopidogrel

M2 MCA severe stenosis MCA PTA

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Stenting catheter navigation MCA stenting DSA post MCA revascularization DSA before ICA and MCA stenting

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DSA post MCA revascularization

Intracranial Atherosclerosis: Ischemic Stroke Mechanisms

• 1. Flow-limiting -> Hypoperfusion -> Deep Watershed Ischemia
• 2. Distal Emboli -> Wedged-Shaped Cortical Infarcts
• 3. Perforator Injury -> Deep “Lacunar” Infarcts

Predicted Event Rates: 30 day 1 year Medical Arm 11% 25% Stenting Arm 5-9% 8-15% SAMMPRIS TRIAL Predicted Event Rates: 30 day 1 year Medical Arm 11% (5.8%) 25% Stenting Arm 5-9% (14.7%) 8-15% SAMMPRIS TRIAL

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WINGSPAN STENT SYSTEM

• 1. Flow-limiting -> Hypoperfusion -> Deep Watershed Ischemia
• 2. Distal Emboli -> Wedged-Shaped Cortical Infarcts
• 3. Perforator Injury -> Deep “Lacunar” Infarcts

Potential Complications

• 4. Reperfusion Injury -> Edema and/or Hemorrhage
• 5. Procedural -> Wire Perforation, SAH/IPH

Important SAMMPRIS Information to Follow

• 1. Influence of Presenting Pattern of

Ischemia and/or Location of Stenosis

• n the Risk of Procedural Ischemia
• 2. Extent/Location of Infarction and

Timing of Revascularization

Future Directions in Cervical and Intracranial Atherosclerosis

• Medical

– new antiplatelets – statins

• Surgical

– CEA for many, CAS for some

• Endovascular: optimization of stenting

– Distal emboli – Perforator occlusion – Patient selection based on stroke type

Thank You

steven.hetts@ucsf.edu