Predicting Stroke
Transcript of Predicting Stroke
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LN Hopkins, MD
Elad Levy, MD
Adnan Siddiqui, MD, PhD
CAS vs CEA: How Would I Approach itwithout a Regulatory Restriction?
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L. Nelson Nick Hopkins, MDI disclose the following financial relationship(s).
Research Grant: Toshiba Speaker/Honoraria, Ownership Interest,
Consultant/Advisory Board: Boston Scientific
Speaker/Honoraria: BARD, Cordis, SCAI
Speaker/Honoraria, Consultant/Advisory Board: Abbott
Consultant/Advisory Board: W. L. Gore
Ownership Interest, Consultant/Advisory Board, Other-Board Member: Micrus
Ownership Interest, Other-Board Member:AccessClosure
Ownership Interest: Valor Medical
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LN Hopkins, MD
Personal Experience
CEA > 2000
CAS > 2000
PI or Co PI or steering committee CREST, CARESS, ARCHeR, CAPTURE,
BEACH, CABANNA, CABERNET, SAPPHIRE,VIVA, Act 1, EMPIRE, ARMOUR
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Life expectancy 5+ years
Severe stenosis
Low GSM, hemorrhagic plaque(MRI),TCD activity MCA, ulcerative lesion
Progression of plaque burden
Evidence of flow restriction/poor perfusion Previous Cerebral Ischemia, ipsi or contralateral
Fully informed patient
No other more obvious source
Asymptomatic PatientsWhen Do We Treat?
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Risk Factor Analysis
High risk CEA
High risk CAS
Evolution in
Experience
Technology
Objective assessment of which procedure looks best foreach patient based on trial results and personalexperience
How to TreatCEA vs CAS
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Predicting Stroke
WHO IS AT
GREATEST RISK??
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Severity of StenosisRisk of Stroke
90-99% 26%
80-89% 18%
70-79% 12%
NASCET
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95% - ulcer = 21% 2yr
95% + ulcer = 73% 2yr
Severe Stenosis + UlcerSTROKE RISK
NASCET
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Intracranial Atherosclerotic Disease
+ Carotid Stenosis
NASCET
Risk of Stroke
Medical Treatment
85-89% Increase
(3 year risk)Ie.Poor Collateral
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Age
Elderly Pts at Highest Risk for Stroke
CEA and CAS
Greatest Benefit in Elderly
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Elderly Patients
NASCET
Risk of Stroke70-99% Sten
Absolute Risk Reduction
Age 75 29%
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Predicting Stroke
Some of the patients atgreatest risk for Stroke arealso at Increased Risk for
CEA
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NASCET / ACAS
CEA effectively reducesstroke risk in Highly
Selected Patients
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Who is at High Risk
for CEA??
CAS Not Yet Approved...
CEA is the ONLY Choice
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CEA is ContraindicatedMedical Comorbidity
Pre-op CABG Angina pectoris
CHF
Recent or evolving MI
Renal failure
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CEA is ContraindicatedSurgical Contraindications
Recurrent carotid stenosis Previous perilesional
- cervical surgery
Contralateral laryngeal palsy Tracheostomy
Post cervical XRT
Biller - Circ 98
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CEA is ContraindicatedAnatomical Contraindications
Lesion above C2
Lesion below clavicle No neck / high bifurcation
- Common Sense
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CEA is Higher Risk
Poor Collateral
Contralateral carotid occlusion
Severe tandem intracranialstenosis
Multivessel occclusion
NASCET I & II
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Neurologic Instability Recurrent CVA
Crescendo TIA
Stroke in evolution
Fluctuating neurologic deficit
Intralumnal thrombus
CEA risk - 14%Seiber, JNS
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62 Year Old Male, Asx Carotid Stenosis
Father died of stroke at age 60CEA or CAS ??
CAS Not YET Approved
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1. Sx (hot) lesion2. Elderly pts
3. Low GSM4. Pre dil without EP5. Tortuousity- perilesional6. Aortic Arch disease7. Multiple stents8. Duration Filter9. Concentric calcium
10.Renal Failure...
CAS Risk FactorsWHEN IS CAS High Risk
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Know who is high risk for CEA
Know who is high risk for stroke
Know who is high risk for CAS
Do what you would do for your Mom
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Thank You!
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