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Carotid Artery Stenosis

Carotid Artery Stenosis . Department of Surgery Queen Elizabeth Hospital Dr Cheng Mina. Questions to answer. Who Who deserves urgent referral? Who needs operation? When When to intervene? What What to do?. Carotid symptoms. Hemimotor / hemisensory signs

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Carotid Artery Stenosis

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  1. Carotid Artery Stenosis Department of Surgery Queen Elizabeth Hospital Dr Cheng Mina

  2. Questions to answer • Who • Who deserves urgent referral? • Who needs operation? • When • When to intervene? • What • What to do?

  3. Carotid symptoms • Hemimotor / hemisensory signs • Transient monocular visual loss (Amaurosis fugax) • Asymptomatic • Carotid bruit • No evidence that presence or absence of bruit or quality of bruit correlate with degree of stenosis J.H. Hammond, R.P. Eisinger: Carotid bruits in 1000 normal subjects. Arch Intern Med. 109, 1962, 563, 5. P.A. Wolf, W.B. Kannel, P. Sorlie, et al.: Asymptomatic carotid bruit and risk of stroke: the Framingham Study. JAMA. 245, 1981, 1442, 5.

  4. Who deserves urgent referral • Risk of stroke after a TIA only 1–2% at 7 days and 2–4% at 30 days M.F. Giles, P.M. Rothwell: The need for emergency treatment of transient ischaemic attack and minor stroke. Expert Rev Neurother. 5, 2005, 203, 10. Naylor: Time is brain. The Surgeon. 5, 2007, 23–30. • Evidence suggests that these data dangerously underestimate the true risk P.M. Rothwell, C.P. Warlow: Timing of TIAS preceding stroke: time window for prevention is very short. Neurology. 64, 2005, 817, 20.PubMed M.F. Giles, P.M. Rothwell: Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol. 6, 2007, 1063, 72.

  5. Who deserves urgent referral • Review of 10126 patients • After TIA 2 day stroke risk 3.1% • 7 day stroke risk 5.2% • ABCD system to predict the 7-day stroke risk after TIA (Max score 6) • A Age > 6o • B SBP > 140mmHg • C Clinical features ( weakness, speech disturbance) • D Duration (< 10 min, 10-59 min, >60 min) • 7-day stroke risk <3 -> 0% 4 -> 2% 5 -> 16% 6-> 35% P.M. Rothwell, M.F. Giles, E. Flossman, et al.: A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack. Lancet. 366, 2005, 29–36

  6. Who deserves urgent referral • UK Department of Health’s National Stroke Strategy • November 2007 • Carotid imaging <24 hours after TIA if ABCD score ≥4 The National Stroke Strategy; www.dh.gov.uk/stroke.

  7. Duplex USG • Combination of B mode real-time imaging and waveform analysis by pulsed wave doppler • Identifies up to 95% of carotid lesions • Sensitivity 89% for 70-99% stenosis • Non-invasive • Operator dependent • Society of Radiologists in USG Consensus Conference • USG criteria for degree of stenosis • Based on the North American Symptomatic Carotid Endarterectomy Trial (NASCET) measurement method • ICA PSV, ICA EDV, plaque estimate, ICA/CCA PSV ratio Grant EG, Benson CB, Moneta GL et al. Carotid artery stenosis: gray-scale and Doppler US diagnosis – Society of Radiologists in Ultrasound Consensus Conference. Radiology 2003; 229:340–6.

  8. 3 methods to measure ICA stenosis • NASCET • ECST • Common carotid method • “Gold standard” • Catheter angiography stroke/death risk 1.5% • Not routine work up nowadays

  9. Contrast enhanced MRA • Sensitivity 95% and specificity 79% for 70–99% stenoses • Sensitivity 100% if combined with USG • Non-invasive • Gadolinium causes nephrogenic systemic fibrosis in 3-5% of patients with renal impairment I. Borisch, M. Horn, B. Butz, et al.: Preoperative evaluation of carotid artery stenosis: comparison of contrast-enhanced MR angiography and duplex sonography with digital subtraction angiography. Am J Neuroradiol. 24, 2003, 1117, 22. D.C. Johnston, J.D. Eastwood, T. Nguyen, et al.: Contrast-enhanced magnetic resonance angiogrophy of carotid arteries. Utility in routine clinical practice. Stroke. 33, 2002, 2834, 8.

  10. Best medical treatment • BP < 140/90 mmHg • DM control • Smoking cessation • Avoid heavy consumption of alcohol • Regular physical activity • Low salt, low saturated fat, high fruit and vegetable diet rich in fibre • Reduce weight if BMI elevated The European Stroke Initiative Executive Committee and the EUSI Writing Committee: European Stroke Initiative recommendations for stroke management – Update 2003. Cerebrovasc Dis. 16, 2003, 311, 37.

  11. Role of statin therapy • The British Heart Protection Study • 20000 patients with angina, stroke/ TIA, DM or claudication • 40 mg simvastatindaily • 25% RRR in any major coronary event, stroke and need of revascularization at 5 years • Irrespective of age, gender or cholesterol level Heart Protection Study Collaborative Group: MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20536 high-risk individuals: a randomised placebo controlled trial. Lancet. 360, 2002, 7–22. • European Stroke Initiative • All patients (symptomatic/ asymptomatic) should take statin The European Stroke Initiative Executive Committee and the EUSI Writing Committee: European Stroke Initiative recommendations for stroke management – Update 2003. Cerebrovasc Dis. 16, 2003, 311, 37.

  12. Antiplatelet agents • Aspirin is the first line agent • Reduces long term risk of stroke by 25% • Low dose is good enough (80 to 325 mg daily) • Clopidogrel(Plavix) 75 mg is the second line agent Antiplatelet Trialists Collaboration: Secondary prevention of vascular disease by prolonged anti-platelet treatment. Br Med J. 296, 1988, 320, 31. • NICE (The National Institute for Health and Clinical Excellence) • Combination of aspirin and dipyridamole (Persantin) for 3 yearsin stroke/TIA patients on conservative treatment • Only aspirin after 3 years or after CEA NICE Technology Appraisal Guidance 90: In Vascular disease – clopidogrel and dipyridamole: quick reference guide. 2005, 25 May.

  13. Who needs operation CEA • Symptomatic • Carotid Endarterectomy Trialists Collaboration (CETC) • Combined data from 3 studies • ECST (European Carotid Surgery Trial) • NASCET (North American Symptomatic Carotid Endarterectomy Trial) • VA (Veteran’s Affairs) • 5 years outcomes, > 6000 patients Carotid Endarterectomy Trialists Collaboration: P.M. Rothwell, M. Eliasziw, S.A. Gutnikov, et al.: Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. for the Lancet. 361, 2003, 107, 16. Carotid Endarterectomy Trialists Collaboration: P.M. Rothwell, M. Eliasziw, S.A. Gutnikov, et al.: Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. for the Lancet. 363, 2004, 915, 24. P.M. Rothwell, M. Eliasziw, S.A. Gutnikov, et al.: Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischaemic attack and minor stroke. Stroke. 35, 2004, 2855, 61.

  14. CEA is not indicated in symptomatic patients with <50% stenosis/ string sign

  15. When to intervene • Maximum risk of stroke is within first 7 to 14 days • Maximum benefit to prevent stroke if < 2 weeks Coull AJ, Lovett JK, Rothwell PM. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organization of services. Br Med J 2004; 328:326–8. Naylor AR. Time is brain! The Surgeon 2007; 5:23–30.

  16. Effect of delay to CEA on 5 year prevention of ipsilateral stroke Reanalysis of CETC data in patients with NASCET 50–99% stenoses (i.e. ECST 70–99%) undergoing CEA

  17. Delay to surgery concept • Early CEA is associated with procedural risk • Retrospective review of 1046 symptomatic patients undergoing CEA in New York • 30 day stroke/death risk • 5.1% <4 weeks 1.6 % >4 weeks C.B. Rockman, T. Maldonado, G.R. Jacobowitz, et al.: Early endarterectomy in symptomatic patients is associated with poorer perioperative outcomes. J Vasc Surg. 44, 2006, 480, 7. • CETC suggests that even if a surgeon operated <2 weeks with a 10% procedural risk, he/she was likely to prevent more strokes than by waiting >12 weeks and then operating with a 0% risk

  18. Asymptomatic carotid stenosis 5 to 10% population >65 years 12% with PVD 25% with HT Prophylactic surgery to prevent stroke Two important studies ACAS Asymptomatic Carotid Atherosclerosis Study 1995 ACST Asymptomatic Carotid Surgery Trial 2004

  19. ACAS 1995/ ACST 2004 • ACAS, 1662 patients • CEA can reduce ipsilateral stroke • Criticism: • 30 day death/stroke only 2.3% (i.e. not generalizable) • No benefit in women • CEA did not prevent disabling stroke • ACST, 3120 patients • CEA significantly reduced risk of fatal and disabling stroke • Significant benefit only in patients <75 years

  20. CEA or carotid stenting? • CAVATAS, SPACE, EVA-3S, ICSS • Widely criticized • E.g. No EPD or not mandatory, no lead-in phase • CREST (Stenting versus Endarterectomy for Treatment of Carotid Artery Stenosis) 2010 • 2522 patients from 2000 to 2008 in USA • Both symptomatic and asymptomatic carotid stenosis • Single carotid stent with EPD system • Lead-in phase

  21. CEA or carotid stenting? • CREST • No significant difference in stroke + MI + death during perioperative period(CAS 5.2%, CEA 4.5%; P = 0.38) and after 4 years (CAS 7.2%, CEA 6.8%; P = 0.51) • More perioperative stroke in CAS group (CAS 4.1%, CEA 2.3%; P = 0.01) • More perioperative MI in CEA group (CAS 1.1%, CEA 2.3%; P = 0.03) • Similar 4-year ipsilateral stroke rate (CAS 2%, CEA 2.4%; P = 0.85) • Younger patients CAS better, older patients CEA better

  22. Individualized treatment • For CAS • Previous neck surgery • Previous neck irradiation • Contralateral vocal cord palsy • Restenosis after CEA • High carotid bifurcation (above C2) • Extension of plaque to intracranial ICA/ proximal CCA below clavicle • For CEA • Poor femoral vessel for access • Heavily calcified or angulated aortic arch • Heavily calcified or markedly tortuous carotid artery

  23. Conclusion • Who • Who deserves urgent referral? • Who needs operation? • When • When to intervene? • What • What to do?

  24. Conclusion • Who • Who deserves urgent referral?ABCD score • Who needs operation? • When • When to intervene? • What • What to do?

  25. Conclusion • Who • Who deserves urgent referral?ABCD score • Who needs operation?Symptomatic 70-99% +/- Symptomatic 50-69%, Asymptomatic 70-99% • When • When to intervene? • What • What to do?

  26. Conclusion • Who • Who deserves urgent referral?ABCD score • Who needs operation?Symptomatic 70-99% +/- Symptomatic 50-69%, Asymptomatic 70-99% • When • When to intervene?< 2 weeks • What • What to do?

  27. Conclusion • Who • Who deserves urgent referral?ABCD score • Who needs operation?Symptomatic 70-99% +/- Symptomatic 50-69%, Asymptomatic 70-99% • When • When to intervene?< 2 weeks • What • What to do?Individualized treatment

  28. Thank You

  29. Stroke Commonest cause of death after CAD and cancer Acute loss of focal cerebral function >24 hrs with vascular cause 80% ischaemic 20% haemorrhagic (intracerebral/ subarachnoid) 80% of ischaemic stroke affect carotid territory

  30. Aetiology of carotid territory infarction Dennis MS, Bamford JM, Sandercock PAG et al. Incidence of transient ischaemic attacks in Oxfordshire, England. Stroke 1989; 20:333–9. Thromboembolism from ICA 50% Small vessel disease 25% Cardiac brain embolism 15% Haematological disease 5% Non-atheromatous disease 5%

  31. Thromboembolism from ICA Middle cerebral vessel territory Atherosclerotic plaque formation Stenosis at ICA origin Acute disruption of plaque Rupture, ulceration, intraplaque haemorrhage Exposure of inner core of thrombogenic subendothelial collagen Thrombus formation

  32. Asymptomatic carotid stenosis • Carotid bruit • 4% over 45 years old, 12% over 60 years old • 70% symptomatic ICA stenosis of 70 to 90% • 40% symptomatic ICA stenosis of 90 to 99% • 30% ICA occlusion • No evidence that presence or absence of bruit or quality of bruit correlate with degree of stenosis • Bruit not due to ICA disease • Systolic cardiac murmurs, bruit from vertebral and ECA J.H. Hammond, R.P. Eisinger: Carotid bruits in 1000 normal subjects. Arch Intern Med. 109, 1962, 563, 5. P.A. Wolf, W.B. Kannel, P. Sorlie, et al.: Asymptomatic carotid bruit and risk of stroke: the Framingham Study. JAMA. 245, 1981, 1442, 5.

  33. Carotid symptoms Hemimotor / hemisensory signs Transient monocular visual loss (Amaurosis fugax) DDX: epilepsy, brain tumour/ aneurysm, hypoglycemia, migraine TIA precipitated by hot bath, heavy meal and exercise -> Significant carotid stenosis should be suspected

  34. Guidelines for imaging • The National Guideline for Stroke 2004 • Duplex finding confirmed with MRA before operation • Or Second duplex if conservative treatment offered J.M. Wardlaw, F.M. Chappell, M. Stevenson, et al.: Accurate, practical and cost-effective assessment of carotid stenosis in the UK. Health Technol Assess. 10, 2006, 1–182, iii–iv, ix–x. • The Society of Radiologists in USG Consensus • All vascular laboratories should have a system for quality assurance • NASCET measurement is mandatory V. Vidak, A. Hebrang, B. Brkljacic, et al.: Stenotic occlusive lesions of internal carotid artery in diabetic patients. Coll Antropol. 31, 2007, 775, 80.

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