Lack of evidence in carotid stenosis

Lack of evidence in carotid stenosis management

Pascual Lozano VilardellAngiología y Cirugía Vascular

Mallorca

ESVS-SEACV Joint Session58 Congreso Nacional SEACV Barcelona 2012

Lack of evidence in symptomatic patients

When should we intervene after an ischemic stroke?


NASCET and ECST confirmed benefit of CEA in the first two weeks after a nondisabling stroke

Current evidence suggests that surgical delay, seems to leave patients at great risk for recurrent cerebral ischemia

Rothwell PM. et al. Time from symptoms to surgery on benefit from CEA for TIA and nondisabling stroke. Stroke 2004;35:2855-2861

Rerkasem K et al. Systematic review of operative risk of CEA for recently symptomatic stenosis. Stroke 2009;40:e564-e572


Urgent CEA in unstable patientsStroke in evolution 20,2%Crescendo TIA

11,4%

Early CEA in stable patients with TIA/minor stroke<2 weeks1,2%

CEA in stable major nondisabling stroke ?

Rockman CB et al. Early carotid endarterectomy in symptomatic patients is assocoated with poorer outcomes. J Vasc Surg 2006;44:480-7


1158 CEAs in TIA/minor stroke

Stroke post CEA:< 4 weeks 5.1%> 4 Weeks 1.6%

p 0.002

GALA trial. Lancet 2008;372:2132-2142


GALA trial: 15% early surgery

Stroke-MI-death post CEA:< 2 weeks 8,2%> 2 Weeks 5,1%

Stroke post CEA:< 2 weeks 6,9%> 2 Weeks 4,3%

CEA/CAS and coronary surgery


Combined CEA-CABGBoth symptomatic

Staged CEA or CASCoronary symptomatic/carotid

asymptomatic

Coronary asymptomatic/carotid symptomatic

Hertzer NR. Basic data concerning associated coronary artery disease in peripheral vascular patients. Ann Vasc Surg 1987;1:616-20


Naylor et al. Eur J Vasc Endovasc Surg 2003;25:380-9Naylor et al. Eur J Vasc Endovasc Surg 2009;37:379-87

30 days death/strokeCEA 10,0% (Staged = combined)

30 days death/strokeCAS 9,1% (asymptomatic)

Probably we should intervene earlyWe don’t know what to do in combinated lesions


SYMPTOMATIC CAROTID STENOSIS

Lack of evidence in asymptomatic patients

Are the results of ACAS and ACST out of date?

ACAS. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421-1428

Halliday A et al. Prevention of disabling and fatal strokes by successful CEA in patients without recent neurologic symptoms: a randomised controlled trial. Lancet 2004;363:1491-1502

Halliday A, et al. 10-year stroke prevention after successful CEA for asymptomatic carotid stenosis (ACST-1): a multicenter randomised trial. Lancet 2010;376:1074-1084

ACAS 5,1% 11,0% 54% 84ACST 6,4% 11,8% 46% 70

10 year risk

ACST 13,4% 17,9% 26%

5 year risk CEA BMT RRR NNT

Are ACAS and ACST out of date?

ESVS, SVS, AHA…

Carotid endarterectomy is indicated in all patients with asymptomatic carotid stenosis > 60%, if periprocedural rate of death-stroke is < 3%


Klein A et al. Management of carotid stenosis- polling results. N Eng J Med 2008,358:e23

Are ACAS and ACST obsolete?Are ACAS and ACST out of date?

2008

Marginal surgical benefit (ARR 1%)Patient selectionNature of interventionResults “in the real world”Neurological auditoriesRol of CAS

Increased evidence for Best Medical TreatmentAggresive medical managementHealthy lifestyle

Abbott AL. Medical intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis. A systematic review. Stroke 2009;573-83


What is the risk of stroke in ACS right now?

Hong K et al. Declining Stroke and Vascular Events Recurrence Rates in Secondary Prevention Trials. Circulation 2011;123:2111-2119

8,71%

4,04%

What is the risk of stroke in Asymptomatic Carotid Stenosis?

Declining of event rates per decade

Recurrent stroke 1,0 %Fatal stroke 0,3 %

Major vascular events 1,3%

Hong K et al. Declining Stroke and Vascular Events Recurrence Rates in Secondary Prevention Trials. Circulation 2011;123:2111-2119


Abbott AL. Medical intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis. Stroke 2009;40:573-583

Stroke type time Decrease

Ipsilateral stroke 1985-2007 1,7%Ipsilateral stroke/TIA 1985-2005 7%

Any stroke 1986-2007 2,3%

Any stroke /TIA 1986-2005 4,2%


Abbott AL. Medical intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis. Stroke 2009;40:573-583

ipsilateral stroke any stroke


Naylor AR. What is the current status of invasive treatment of extracraneal carotid artery disease? Stroke 2011;42:2080-85

3,5%

2,4%

1,4%

2,2%

1,1% 0,7%


ipsilateral strokeany stroke

OXFORD VASCULAR STUDY (2002-2009)

1200 patients with TIA / stroke

101 patients with ACS intensive MT

Marquardt L et al. Low risk of ipsilateral stroke in patients with ACS on best medical treatment. Stroke 2010;41:11-17


Annual ipsilateral stroke rate 0,34%

There are patients at high stroke risk?Can we identify this patients?

There are patients at high stroke risk?Can we identify this patients?

Clinical features

Degree of stenosis

Progression of stenosis

Plaque characteristics

Cerebrovascular reactivity

Microembolism

Silent infarcts

Biomarkers

Hirt LS. Stroke. 2011;42Nicolaides AN et al. Eur J Vasc Endovasc Surg. 2005;30:275-284

Independent risk predictors of ipsilateral events:

- Previous contralateral events (21.6% vs 14.7%)

- History of contralateral TIAs (RR 3.0; 95% CI 1.90-4.73)

There are asymptomatic patients at high risk of stroke?Clinical features

Kakkos SK et al. J Vasc Surg 2009;49:902-9Rijbroek A et al. Eur Neurol 2006;56:139-154

Neither ACAS nor ACST demonstrated any relationship between stenosis severity and late risk of stroke

Discrepance with other natural history studies: Degree of stenosis identified as an independent predictor of ipsilateral neurologic events (p=0.019)

There are asymptomatic patients at high risk of stroke?Degree of stenosis

There are asymptomatic patients at high risk of stroke?Progression of stenosis

Hirt LS. Progression rate and ipsilateral neurological events in ACS. Stroke 2011;42

Jayasooriya G et al. J Vasc Surg 2011;54:227-36

There are asymptomatic patients at high risk of stroke?Carotid plaque vulnerability: MICROEMBOLISM

Markus HS et al. Asymptomatic embolisation for prediction of stroke in the ACES: a prospective observational study. Lancet Neurol 2010;9:663-671

Patients with MES Mean number MES

10% 2,63 (1-20)


ipsilateral stroke

MES 3,62%No MES 0,70%

Spence JD et al. Effects of Intensive Medical Therapy on Microemboli and Cardiovascular Risk in ACS. Arch Neurol 2010;67:180-86

Patients with MES Carotid plaqueprogression

Cardiovascular events

2000-2002 12,6% 69 mm2 17,6%2003-2007 3,7% 23 mm2 5,6%


Intensive medical therapy

468 patients with ACS > 70%

There are asymptomatic patients at high risk of stroke?COMBINATION SCORES: ACES

Topakian R et al. Neurology 2011;77:751-758

ipsilateral stroke

Echolucency + MES 8,90%None 0,80%

Nicolaides AN et al. ACS and cerebrovascular risk stratification. J Vasc Surg. 2010;52:1486-96

There are asymptomatic patients at high risk of stroke?COMBINATION SCORES: ACSRS

a)Stenosis alone: 0.59b)Stenosis + clinical features (smoking, contralateral stroke/TIA): 0.66c)Stenosis + plaque characteristics + previous contralateral TIA/stroke: 0.82

There is place for angioplasty in ACS?


CREST ASYMPTOMATIC periprocedural 4 yearsCEA 1,4% 2,7%CAS 2,5% 4,5%

Death-stroke. MI excluded

Brott et al. Stenting versus endarterectomy for treatment of carotid artery stenosis. N Eng J Med 2010;363:11-13


periprocedural SVS REGISTRY

CEA 2,0 %CAS 4,6 %

Combined death-stroke-MI

Giles KA et al. Stroke and death after CEA and CAS with and without high risk criteria. J Vasc Surg 2010;52:1497-1504

ACAS and ACST results are being questionedWe don’t know the exact risk of stroke of ACSProbably there are patients at very low stroke riskProbably there are patients at high stroke riskWe don’t have standardized methods to identify this patientsProbably no place for rutinary CEA or CAS in ACS


ASYMPTOMATIC CAROTID STENOSIS

So we need more RCT in Asymtomatic Carotid Stenosis

Lack of evidence in carotid stenosis

Health & Medicine

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