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

▶
the carotid artery
SMART_READER_LITE
LIVE PREVIEW

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

Feb 17, 2024 242 likes •754 views

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

slide-1
SLIDE 1

THE CAROTID ARTERY

Prof Astarci Parla

Head of the Cardiovascular Department Cliniques Universitaires Saint-Luc Brussels

Cardiology 21 May 2016

slide-2
SLIDE 2

Prof Astarci Parla

slide-3
SLIDE 3

Prof Astarci Parla

slide-4
SLIDE 4

Prof Astarci Parla

  • 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

Stroke

slide-5
SLIDE 5

Prof Astarci Parla

Etiology of Stroke

  • 1. Atherosclerotic disease
slide-6
SLIDE 6

Prof Astarci Parla

Etiologies

  • A. AF
  • B. Post Coronary Angyo
  • C. …
  • 1. Atherosclerotic disease
  • 2. Embolic
slide-7
SLIDE 7

Prof Astarci Parla

Etiologies

  • 1. Atherosclerotic disease
  • 2. Embolic
  • 3. Dissection
slide-8
SLIDE 8

Prof Astarci Parla

Etiologies

  • 1. Atherosclerotic disease
  • 2. Embolic
  • 3. Dissection
  • 4. Takayasu
slide-9
SLIDE 9

Prof Astarci Parla

Etiologies

  • 1. Atherosclerotic disease
  • 2. Embolic
  • 3. Dissection
  • 4. Takayasu
  • 5. Post radiotherapy
slide-10
SLIDE 10

Prof Astarci Parla

slide-11
SLIDE 11

Prof Astarci Parla

slide-12
SLIDE 12

Prof Astarci Parla

slide-13
SLIDE 13

Prof Astarci Parla

slide-14
SLIDE 14

Prof Astarci Parla

slide-15
SLIDE 15

Prof Astarci Parla

slide-16
SLIDE 16

Prof Astarci Parla

slide-17
SLIDE 17

Prof Astarci Parla

slide-18
SLIDE 18

Prof Astarci Parla

slide-19
SLIDE 19

Prof Astarci Parla

Our Experience in St-Luc

TEA + Patch 89% Eversion 9% Bypass 2%

slide-20
SLIDE 20

Prof Astarci Parla

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)

When do you need shunt ?

slide-21
SLIDE 21

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
slide-22
SLIDE 22

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

slide-23
SLIDE 23

Prof Astarci Parla

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)

When do you need shunt ?

Shunt if stump pressure < 40 mmHg

RESULTS

  • No deficit

91.3% (263/288)

  • Pre-existing deficit

8.3% (24/288)

  • New deficit

0.3% (1/288)

slide-24
SLIDE 24

Prof Astarci Parla

  • 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.

History of Carotid Surgery

slide-25
SLIDE 25

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

slide-26
SLIDE 26

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)

North American Symptomatic Carotid Trial

– 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

slide-27
SLIDE 27

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)

European Carotid Surgery Trial

–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

slide-28
SLIDE 28

Prof Astarci Parla

Measurement differences between ESCT and Nascet

slide-29
SLIDE 29

Prof Astarci Parla

Asymptomatic Carotid Surgery

■ 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)

ACST: Asymptomatic Carotid Surgery Trial

  • Stroke. 2004; 35: 2425-2427
slide-30
SLIDE 30

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

slide-31
SLIDE 31

Prof Astarci Parla

Surgery is the BEST

slide-32
SLIDE 32

Prof Astarci Parla

What ? a wound in my neck…

slide-33
SLIDE 33

Prof Astarci Parla

Carotid angioplasty stenting

slide-34
SLIDE 34

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)
slide-35
SLIDE 35

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)

slide-36
SLIDE 36

Prof Astarci Parla

Carotid angioplasty stenting

slide-37
SLIDE 37

Prof Astarci Parla

Carotid protection device

Spider (EV3)

slide-38
SLIDE 38

Prof Astarci Parla

EPI- EZ (Boston Medical)

Carotid protection device

slide-39
SLIDE 39

Prof Astarci Parla

Results of carotid angioplasty

■ 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

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.

slide-40
SLIDE 40

Prof Astarci Parla

Results of carotid angioplasty

Lower incidence of 30-days adverse events:

CAS CEA stroke 3.8 5.3 death 0.6 2 MI 2.6 7.3

Combined risk for CAS: 6.4% versus CEA: 12.6% p<0.05

p=NS p=NS p=NS

slide-41
SLIDE 41

Prof Astarci Parla

Results of carotid angioplasty

■ 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

CaRESS Carotid Revascularisation using endarterectomy or stenting systems

J Vasc Surg. 2005 Aug;42(2):213-9.

slide-42
SLIDE 42

Prof Astarci Parla

Results of carotid angioplasty

■ Symptomatic, randomised ■ 1200 pts à 605 CAS

à 595 CEA Stroke/death rate 30 days: 6.8% CAS 6.34% CEA (p=0.09)

SPACE Stent-Protected Angioplasty versus Carotid Endarterectomy in symptomatic patients

  • Lancet. 2006 Oct 7;368(9543):1239-47
slide-43
SLIDE 43

Prof Astarci Parla

Results of carotid angioplasty

■ 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!

EVA-3S Endarterectomy versus Stenting in patients with Symptomatic Severe Carotid Stenosis…

N Engl J Med. 2006 Oct 19;355(16):1660-71.

slide-44
SLIDE 44

Prof Astarci Parla

Cardiac surgery and carotid stenosis

slide-45
SLIDE 45

Prof Astarci Parla

Cardiac surgery and carotid stenosis

slide-46
SLIDE 46

Prof Astarci Parla

Cardiac surgery and carotid stenosis

slide-47
SLIDE 47

Prof Astarci Parla

NO benefit for combined surgery

Cardiac surgery and carotid stenosis

slide-48
SLIDE 48

Prof Astarci Parla

CONCLUSIONS

  • 1. The carotid surgery is the best treatment for

symptomatic and asymptomatic carotid stenosis

  • 2. INDICATIONS for treatment
  • 1. >70% if Symptomatic
  • 2. >80-85% if Asymptomatic
  • 3. Carotid angioplasty and stenting can be used for

asymptomatic lesions in selected cases.

slide-49
SLIDE 49

Prof Astarci Parla

Good old methods are still the best! We just need to convince people !!!

CONCLUSIONS

slide-50
SLIDE 50

Prof Astarci Parla