THE CAROTID ARTERY Prof Astarci Parla Head of the Cardiovascular - PowerPoint PPT Presentation

THE CAROTID ARTERY Prof Astarci Parla Head of the Cardiovascular Department Cliniques Universitaires Saint-Luc Brussels Cardiology 21 May 2016

Prof Astarci Parla

Prof Astarci Parla

Stroke • Stroke = 90 000 death /year in France • Third cause of death • Evolution of non fatal stroke • 1/3 complete recovery • 1/3 recovery with plegia • 1/3 complete dependence Prof Astarci Parla

Etiology of Stroke 1. Atherosclerotic disease Prof Astarci Parla

Etiologies 1. Atherosclerotic disease 2. Embolic A. AF B. Post Coronary Angyo C. … Prof Astarci Parla

Etiologies 1. Atherosclerotic disease 2. Embolic 3. Dissection Prof Astarci Parla

Etiologies 1. Atherosclerotic disease 2. Embolic 3. Dissection 4. Takayasu Prof Astarci Parla

Etiologies 1. Atherosclerotic disease 2. Embolic 3. Dissection 4. Takayasu 5. Post radiotherapy Prof Astarci Parla

Prof Astarci Parla

Prof Astarci Parla

Prof Astarci Parla

Prof Astarci Parla

Prof Astarci Parla

Prof Astarci Parla

Prof Astarci Parla

Prof Astarci Parla

Prof Astarci Parla

Our Experience in St-Luc TEA + Patch 89% Eversion 9% Bypass 2% Prof Astarci Parla

When do you need shunt ? Stump Pressure and Somatosensory Evoked Potentials for Predicting the Use of Shunt During Carotid Surgery 
 P. Astarci, J.M. Guerit, A. Robert, G. Elkhoury, P. Noirhomme, J. Rubay, V. Lacroix, A. Poncelet, J.C. Funken, D. Glineur, R. Verhelst 
 Annals of Vascular Surgery 
 May 2007 (Vol. 21, Issue 3, Pages 312-317) Prof Astarci Parla

When do you need shunt ? • 288 patients with 75% males (217) • Mean % of stenosis 85% • Symptomatic 51 % (146) • All with SSEP (SomatoSensory Evoqued Potentiel) • All with Stump Pressure Measurement Prof Astarci Parla

When do you need shunt ? • Somatosensory Evoqued Potentiel – No modification 78.1% (225) – Middle modification 11.1% (32) – Severe modification 10.8% (31) • Surgical technic – Mean Stump Pressure 51 mmHg – Per-Op Shunt 16.3% (47patients) – Time without shunt 20 min – Delay clamp-SSEP 6 min – Time with shunt 31 min Prof Astarci Parla

When do you need shunt ? Stump Pressure and Somatosensory Evoked Potentials for Predicting the Use of Shunt During Carotid Surgery 
 P. Astarci, J.M. Guerit, A. Robert, G. Elkhoury, P. Noirhomme, J. Rubay, V. Lacroix, A. Poncelet, J.C. Funken, D. Glineur, R. Verhelst 
 Annals of Vascular Surgery 
 May 2007 (Vol. 21, Issue 3, Pages 312-317) RESULTS • No deficit 91.3% (263/288) • Pre-existing deficit 8.3% (24/288) • New deficit 0.3% (1/288) Shunt if stump pressure < 40 mmHg Prof Astarci Parla

History of Carotid Surgery ● 1914: Hunt: carotid stenosis causes stroke ● 1927: Moniz: cerebral arteriography ● 1951: Carrea: Anastomosis ECA-ICA ● 1953: De Bakey: TEA for total occlusion ● 1954: Eastcott: Resection + e-e anastomosis (may) TEA for carotid stenosis (june) ● 1980: Most common vascular procedure in USA and Europe. Prof Astarci Parla

Fall and Rise of CEA 
 ● Doubt about effectiveness and patient selection – Warlow: Is it safe to auscultate the neck? – Callow: Carotid endarterectomy: an expression of concern – Sandercock: Asymptomatic carotid stenosis: spare the knife ● Anti-platelet drugs (aspirin, ticlopidine) ● Need for large randomized studies – NASCET – ECST Prof Astarci Parla

Evidence for CEA in symptomatic patients ● NASCET Stroke 1999; 30: 1751-1758 – 659 symptomatic patients with > 70% stenosis (1991) » Perioperative stroke and mortality: 5.8% Death: 0,6% Major stroke:1,5% » 2 years follow-up: ipsilateral stroke-rate Medical: 26 % Surgical: 9% (p<0.05) – 2226 symptomatic patients with 30-70% stenosis (1998) » 50-70% : 5 year stroke rate: Medical: 22.2% Surgical: 15.7% (p<0.05) » < 50%: No significant benefit even at 5 years North American Symptomatic Carotid Trial Prof Astarci Parla

Evidence for CEA in symptomatic patients ● ECST Lancet. 1998;351:1379-87 –778 symptomatic patients with > 70% stenosis (1991) »Perioperative stroke and mortality: 7.5% Death: 0,9% Major stroke: 3,7% »3 years follow-up: death and stroke-rate: Medical: 21.9% Surgical: 12.9% (p<0.05) –3023 symptomatic patients with 30-70% (1998) »Perioperative stroke and mortality: 7.0% »50-70% stenosis: 3 year stroke-rate Medical: 26.5% Surgical: 14.9% (p<0.05) »No benefit for < 50% stenosis European Carotid Surgery Trial Prof Astarci Parla

Measurement differences between ESCT and Nascet Prof Astarci Parla

Asymptomatic Carotid Surgery ACST: Asymptomatic Carotid Surgery Trial Stroke. 2004; 35: 2425-2427 ■ Multicentric, selected team, 5 year follow-up ■ Asymptomatic Stenosis >70% ■ Randomised but no high surgical risk ■ 3120 pts -> 1560 CEA 1560 medical care Stroke rate at 5 years CEA:3,1% / Medical care:11% High significant reduction at 5-year risk (p<0.01) Prof Astarci Parla

Evidence for CEA in asymptomatic patients ● CASANOVA, MACE, AURC, Veterans ● ACAS – 1662 asymptomatic patients > 70 % stenosis – Peri-operative stroke and death: 2,3 % (1,2% due to angiography !) – 5-year stroke-rate: Medical : 10,6% Surgical: 4,8% p<0.05 only after 5 years Prof Astarci Parla

Surgery is the BEST Prof Astarci Parla

What ? a wound in my neck… Prof Astarci Parla

Carotid angioplasty stenting Prof Astarci Parla

Carotid angioplasty stenting ● 1981: Mathias: First case described ● Evolution –Angioplasty alone –Stenting ( after 1990 ) –Low profile systems … –Protection devices (Théron 1987) –? ● No evidence of safety or efficacy ● Number of procedures increasing (40%/yr) Prof Astarci Parla

Are the results ameliorating? • Mathias – 1981: 1st case – 1994: 305 cases: 2% neurological complications (Radiology) – 1999: 799 cases: 7,7% neurological complications (Radiologe) • Théron – 1987: 11 cases – 1992: 123 cases: 2% complications (Int. Neuroradiology) – 1996: 174 cases: 4% neurological complications (J.Mal.Vasc) – 1998: 218 cases: 4,5% neurological complications (Marseille) • Henry – 1998: 173 cases: 4,6% neurological complications (J Endovasc Surg) – 2000: 315 cases: 4,5% neurological complications (Texas Heart J) Prof Astarci Parla

Carotid angioplasty stenting Prof Astarci Parla

Carotid protection device Spider (EV3) Prof Astarci Parla

Carotid protection device EPI- EZ (Boston Medical) Prof Astarci Parla

Results of carotid angioplasty SAPPHIRE The Stenting and Angioplasty with Protection in Patients at High risk for endarterectomy N Engl J Med. 2004 Oct 7;351(15):1493-501. ■ Prospective, randomized, sympto + asympto ■ 307 ppts -> 157 stenting 151 CEA ■ 33% symptomatic and 67% asymtomatic EXCLUSION criteria: congestive heart failure (NYHA III/IV), LVEF <30%, Cardiac surgery within 6 week Recent MI, Unstable angina Severe pulmonary disease Contralat carotid occlusion Contralat laryngeal nerve palsy, Radiation therapy of the neck, Radical neck surgery Previous endarterectomy with recurrent stenosis High cervicall ICA stenosis or CCA lesions below the clavicle Severe tandem lesions Age>80 Prof Astarci Parla

Results of carotid angioplasty Lower incidence of 30-days adverse events: CAS CEA stroke 3.8 5.3 p=NS death 0.6 2 p=NS MI 2.6 7.3 p=NS Combined risk for CAS: 6.4% versus CEA: 12.6% p<0.05 Prof Astarci Parla

Results of carotid angioplasty CaRESS Carotid Revascularisation using endarterectomy or stenting systems J Vasc Surg. 2005 Aug;42(2):213-9. ■ Multicentric, non randomised USA ■ Symptomatic + Asymptomatic ■ 143 CAS+EPD (31% sympto,84% high risk) Wallstent Boston - Guidewire Plus Medtronic ■ 254 CEA (33% sympto, 87% high risk) Stroke/death rate 30 days:3,6% CEA – 2,1% CAS but p=NS Mi 30 days, stroke/death 1 year, restenosis: ns Prof Astarci Parla

Results of carotid angioplasty SPACE Stent-Protected Angioplasty versus Carotid Endarterectomy in symptomatic patients Lancet. 2006 Oct 7;368(9543):1239-47 ■ Symptomatic , randomised ■ 1200 pts à 605 CAS à 595 CEA Stroke/death rate 30 days: 6.8% CAS 6.34% CEA (p=0.09) Prof Astarci Parla

Results of carotid angioplasty EVA-3S Endarterectomy versus Stenting in patients with Symptomatic Severe Carotid Stenosis… N Engl J Med. 2006 Oct 19;355(16):1660-71. ■ Multicentric ■ Symptomatic stenosis, 60-99 % ■ Randomized: CEA-CAS ! started 2000 but systematic use of EPD since 2003 ■ Team: neuro:follow-up/Vasc surg: >25 CEA/year/Intervent:>12 stent ■ 514 pts -> 257 CEA 247 CAS CEA 30-day stroke/death 3,9% CAS 9,6% (7,9% if EPD- 25% without EPD) CEA disabling stroke/death 1,5% CAS 3,4% p = NS local or systemic complications Study was stopped ! Prof Astarci Parla

Cardiac surgery and carotid stenosis Prof Astarci Parla

Cardiac surgery and carotid stenosis Prof Astarci Parla

Cardiac surgery and carotid stenosis Prof Astarci Parla

Cardiac surgery and carotid stenosis NO benefit for combined surgery Prof Astarci Parla