2014session5 3

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2014session5 3

  1. 1. Congrès de l’ACVQ Entretiens Vasculaires 2014 Pascal Rhéaume Chirurgie Vasculaire CHU de Québec Aucune sténose carotidienne ne devrait être opérée
  2. 2. Conflits d’Intérêts • Consultant: COOK Medical
  3. 3. Un homme de 67 ans connu pour HTA et dyslipidémie sous traitement avec ASA, hydrochlorothiazide et Simvastatin présente un souffle carotidien gauche. Au questionnaire le patient est asymptomatique. Au Doppler on démontre une sténose de 70-80% Quel est votre approche? 1)Traitement médical 2)Endartérectomie carotidienne 3)Angioplastie carotidienne avec tuteur
  4. 4. Avant - Après
  5. 5. Avant - Après
  6. 6. Avant - Après
  7. 7. Avant - Après
  8. 8. Avant - Après
  9. 9. • « Scientists tend to work within one set of ideas about how the world is. Everything they do, be it experimental or theoretical, is informed by, and framed within, that set of ideas. However, there will be evidence that does not fit. At first, that evidence will be ignored or sabotaged. Eventually though, the anomalies will pile up so high that they simply cannot be ignored or sabotaged any longer. Then comes crisis » -Thomas Kuhn
  10. 10. Arguments déjà entendus: •S’il s’agissait de maladie cardiaque •Recommandation de AHA sont basées sur les plus grandes évidences •50% de réduction d’AVC si opéré •Les complications péri-opératoires sont en diminution •Politiquement incorrecte de refuser la chirurgie aux femmes •Mais le patient lui , il retient quoi? •80% des AVC n’ont pas de Sx prémonitoire •Les patients ne sont pas compliants à leur médication •Mettons l’emphase sur l’individu et non la population
  11. 11. Arguments à entendre: •Les bénéfices exposés par ACAS/ACST sont minimes •Peu de consensus et l’AHA recommande l’endartérectomie chez les patients hautement sélectionnés sans autre définition •La vaste majorité des patients subissant une réparation n’étaient jamais destinés à souffrir d’un AVC •La vaste majorité des patients subiront une intervention non nécessaire, mobilisant beaucoup de ressources inutilement •Traitement médical a changé l’histoire naturel de la maladie asymptomatique •La population à risque demeure à être définie
  12. 12. CASANOVA 206 pts - 334endarterectomies End points:AVC, Mortalité à 3 ans Résulats: Médical: 10,7% Chirurgie: 11,3% p=0,486 Limitation: Beaucoup de cross-over ICT non considérés échec Randomisation complexe
  13. 13. MACE • Publiée en 1992 • Seulement 71 patients • Pas d’analyse valable car trop peu d’événement neurologique • Étude terminée car trop de complications cardiaques et ICT dans le groupe chirurgical • Absence d’ASA Carotid Revascularization for Prevention of Stroke: Carotid Endarterectomy and Carotid Artery Stenting Thomas G. Brott, MD, Robert D. Brown Jr, MD, MPH, Fredric B. Meyer, MD, David A. Miller, MD, Harry J. Cloft, MD, PHD, Timothy M. Sullivan, MD
  14. 14. VA-Asymptomatic 444 hommes avec sténose de >50% End points: AVC et Mortalité Durée: 1983-1991; suivi moyen 4 ans Traitement médical: ASA 325mg bid Exclusion: EV <5 ans, haut risque chirurgical
  15. 15. VA -Asymptomatic
  16. 16. VA -Asymptomatic
  17. 17. VA-Asymptomatic Limitations: Seulement des hommes Différence présente pour endpoints combinés ICT + AVC ICT et AVC analysés ensemble Pas de différence pour AVC seul (Manque de puissance) Pas de différence pour AVC + Mortalité
  18. 18. ACAS • 1662 patients Décembre 1987 et décembre 1993 • Hommes et femmes 40-79 ans • Artério ou doppler >60%; tous ont eu artério • Traitement médical: ASA 325mg • Endpoints: Changement en cours d’étude – Initial: Tout ICT/AVC Ispi ou tout ICT/AVC périop ou mortalité – Ensuite: Seulement AVC Ispi ou tout AVC périop ou mortalité
  19. 19. ACAS
  20. 20. • Suivi médian 2,7 ans • Extrapolation des résultats à 5 ans • Diminution du risque absolu: 5,9% (1% par année) • Diminution du risque relatif: 53% • Morbidité neuro/mortalité opératoire: 2,3% (2,7% incluant angio) • Bénéfice plus grand chez homme que femme (66% vs 17%; NS) • Complications périopératoires homme 1,7%; Femme 3,7% (NS) • Pas de bénéfice en lien avec degré de sténose • Tendance à bénéfice chez patients plus jeunes mais non significatif
  21. 21. • Exclusion de 40% des chirurgiens • Pas de puissance pour les sous-groupes • Changement de protocole en cours d’étude • Traitement médical variable(seulement ASA) • Résultats extrapolés à 5 ans • Exclusion >80 ans, MCAS récent ou EV diminuée • Risque périopératoire bas comparativement au résultats de population
  22. 22. ACST-5 ans • 3120 hommes et femme de avril 1993- juillet 2003 • Doppler ou artério: Sténose >60% • Exclusion des patients à haut risque • Endpoints: Morbidité neuro et mortalité périopératoire Incidence d’événement neurologique
  23. 23. ACST-5 ans
  24. 24. ACST-5 ans • Suivie moyen 3.4 ans – résultats à 5 ans • Risque périopératoire 3,1% (AVC ou mortalité) • Réduction absolu de 5,4% et relatif de 50% • Bénéfice chez femmes seulement si risque périopératoire exclu • Pas de relation avec degré de sténose • Pas de bénéfice si >75 ans • Augmentation des statines durant étude
  25. 25. ACST-10 ans
  26. 26. ACST-10 ans
  27. 27. Évidence should possibly stop intervening altogether in asymptomatic patients.15,16 ACAS3 and ACST4,5 failed to resolve the debate about the treatment of asympto- published, the largest single increase in the number of CEA procedures in the US state of Florida (93% increase) was in patients aged >84 years.17 Second, concerns were expressed Table 1| Outcomes from ACAS and ACST Trial n Operative risk (%) Risk of stroke with BMT (%) Risk of stroke with CEA* (%) ARR with CEA (%) RRR with CEA (%) NNT with CEA Strokes prevented per 1,000 CEAs 5-year outcomes ACAS3 1,662 2.3 11.0 5.1 5.9 54 17 59 ACST4 3,120 2.8 11.8 6.4 5.4 46 19 53 10-year outcomes ACST5 3,120 2.8 17.9 13.4 4.6 26 22 46 *The 5-year and 10-year CEA data include the 30-day risk of death or stroke. Abbreviations: ACAS, Asymptomatic Carotid Atherosclerosis Study; ACST, Asymptomatic Carotid Surgery Trial; ARR, absolute risk reduction in stroke; BMT, best medical therapy; CEA, carotid endarterectomy; NNT, number needed to treat to prevent one stroke; RRR, relative risk reduction in stroke. P E R S P E C T I V E S should possibly stop intervening altogether in asymptomatic patients.15,16 ACAS3 and ACST4,5 failed to resolve the debate about the treatment of asympto- published, the largest single increase in the number of CEA procedures in the US state of Florida (93%increase) was in patients aged >84 years.17 Second, concerns were expressed Table 1| Outcomes from ACAS and ACST Trial n Operative risk (%) Risk of stroke with BMT (%) Risk of stroke with CEA* (%) ARR with CEA (%) RRR with CEA (%) NNT with CEA Strokes prevented per 1,000 CEAs 5-year outcomes ACAS3 1,662 2.3 11.0 5.1 5.9 54 17 59 ACST4 3,120 2.8 11.8 6.4 5.4 46 19 53 10-year outcomes ACST5 3,120 2.8 17.9 13.4 4.6 26 22 46 *The 5-year and 10-year CEA data include the 30-day risk of death or stroke. Abbreviations: ACAS, Asymptomatic Carotid Atherosclerosis Study; ACST, Asymptomatic Carotid Surgery Trial; ARR, absolute risk reduction in stroke; BMT, best medical therapy; CEA, carotid endarterectomy; NNT, number needed to treat to prevent one stroke; RRR, relative risk reduction in stroke. P E R S P E C T I V E S
  28. 28. Quel est le problème?
  29. 29. Quel est le problème? SYMPTOMATIQUE •Accepté interdisciplinaire •Différence considérable •Analyse de sous groupe ASYMPTOMATIQUE •Discordance interdisciplinaire •Différence mineure •Peu d’analyse de sous-groupe
  30. 30. Considérations historiques Années Faits 1991 40% des chirurgiens applicants rejetés 1995 Avec un risque de 2,3%, CEA prévient 59 AVC/1000 sur 5 ans Incluant le risque chx, CEA confère pas de bénéfice au femmes (ACAS) Pas de lien entre degré de sténoses et risque AVC (ACAS) 1997 Canadian Stroke Consortium ne recommande pas CEA et dépistage 2000 CEA ne confère pas de bénéfice chez occlusion contralatéral (ACAS) 55% des AVC retardé sont d’origine cardioembolique (ACAS) 2001 Risque périopératoire >3% dans 7 États sur 10 (moyenne 5,9%) 2002 Si ACAS avait été analysé à 4 ans: Pas de bénéfice ( NASCET investigators) 2003 Europena Stroke Initiative: Tx médical est probablement meilleur 2004 Pas de bénéfice chez > 75 ans (ACST) Pas d’association entre sévérité et bénéfice (ACST) Si risque chx inclus: Pas d’avantage chez la femmes (ACST) Risque chirurgical 5,4% dans 10 États basés sur critère d’ACST Méta-analyse démontre mortalité 8 fois plus grande que ACAS Méta-analyse démontre AVCMortalité 3 fois plus grande que ACAS
  31. 31. Considérations historiques Années Faits 2005 92% des CEA au USA sont Asymptomatiques 2007 US Preventive Service Task force ne recommande pas dépistage 2008 Le risque d’AVC annuel est en déclin depuis 20 ans 2009 Revvue systmatique démontre que Tx médical est plus sécuritaire 2010 Statine à haute dose diminue les risque d’AVC ACST-10ans démontre RRA de 4,6% (0,46%par année) 2011 Évaluation post-CREST démontre que l’évidence d’intervenir est faible et que CAS ne devrait pas être offert avant d’autre données
  32. 32. Manque de Consensus
  33. 33. Manque de Consensus Although surgery reduces the incidence of ipsilateral stroke, the absolute benefit of carotid surgery is small, as the rate of stroke in medically treated patients is low [Benavente et al., 1998]. Medical management alone is the best alternative for many asymptomatic subjects.
  34. 34. Manque de Consensus
  35. 35. Manque de Consensus A 67-year-old man with a history of hypertension and hyperlipidemia is seen for a routine examination. His medications include hydrochlorothiazide (25 mg daily), simvastatin (20 mg daily), and aspirin (81 mg daily). Auscultation of the neck shows normal carotid upstrokes but reveals a middle-pitched bruit only in systole at the angle of the right jaw. A detailed neurologic examination is normal. On questioning, the patient does not report any history of transient neurologic deficits — specifi- cally, no unilateral weakness or sensory symp- toms, visual disturbances, or speech or language difficulty. Noninvasive testing of the carotid arteries re- veals a stenosis of 70 to 80% of the proximal right,
  36. 36. Manque de Consensus
  37. 37. Conflits d’Intérêts
  38. 38. Manque de Concensus … evidence for any invasive treatment of asymptomatic carotid disease is weak, with recent data favouring purely medical management …more contemporary data are needed on the medical management of asymptomatic carotid disease before either CAS or CEA can be recommended… …there is a danger that CREST will be interpreted as sanctioning treatment of asymptomatic disease, which is not warranted by the available data.
  39. 39. Sous-groupes? • Femmes – Bien reconnu dans NASCET – ACAS: Pas de bénéfice pour les femme meme si risque périopératoire exclu – ACTS: Bénéfice seulement si risque opératoire exclu • Age >75 ans – ACAS: Pas de données suffisante (Inclusion <80ans) – ACST: Pas d’avantage au >75 ans
  40. 40. Sous-groupes? • Degré de sténose – ACST: Bénéfice seulement si risque périprocédure est exclue – ACAS: Pas de bénéfice même si risque périprocédure exclu – Pas de bénéfice lorsque données combinées • Sténose contralatérale – Bien reconnu dans NASCET – ACAS: - Peu de patient - Patient pas plus à risque
  41. 41. Intervention de masse • But Ultime: Prévention d’événement should possibly stop intervening altogether 15,16 published, the largest single increase in the Table 1| Outcomes from ACAS and ACST Trial n Operative risk (%) Risk of stroke with BMT (%) Risk of stroke with CEA* (%) ARR with CEA (%) RRR with CEA (%) NNT with CEA Strokes prevented per 1,000 CEAs 5-year outcomes ACAS3 1,662 2.3 11.0 5.1 5.9 54 17 59 ACST4 3,120 2.8 11.8 6.4 5.4 46 19 53 10-year outcomes ACST5 3,120 2.8 17.9 13.4 4.6 26 22 46 *The 5-year and 10-year CEA data include the 30-day risk of death or stroke. Abbreviations: ACAS, Asymptomatic Carotid Atherosclerosis Study; ACST, Asymptomatic Carotid Surgery Trial; ARR, absolute risk reduction in stroke; BMT, best medical therapy; CEA, carotid endarterectomy; NNT, number needed to treat to prevent one stroke; RRR, relative risk reduction in stroke. P E R S P E C T I V E S should possibly stop intervening altogether 15,16 published, the largest single increase in the Table 1| Outcomes from ACAS and ACST Trial n Operative risk (%) Risk of stroke with BMT (%) Risk of stroke with CEA* (%) ARR with CEA (%) RRR with CEA (%) NNT with CEA Strokes prevented per 1,000 CEAs 5-year outcomes ACAS3 1,662 2.3 11.0 5.1 5.9 54 17 59 ACST4 3,120 2.8 11.8 6.4 5.4 46 19 53 10-year outcomes ACST5 3,120 2.8 17.9 13.4 4.6 26 22 46 *The 5-year and 10-year CEA data include the 30-day risk of death or stroke. Abbreviations: ACAS, Asymptomatic Carotid Atherosclerosis Study; ACST, Asymptomatic Carotid Surgery Trial; ARR, absolute risk reduction in stroke; BMT, best medical therapy; CEA, carotid endarterectomy; NNT, number needed to treat to prevent one stroke; RRR, relative risk reduction in stroke. P E R S P E C T I V E S 90% 80%
  42. 42. Intervention de masse • Calcul efficacité – Pour 100 AVC… – 100 - 20 d’origine hémoragique = 80 – 80 – 20 d’origine vertébrobasilaire = 60 – 60 x 50% d’origine carotidienne = 30 – 30 – 20 (23 Sténose < 60%) = 10 – 10 x 80% d’AVC franc = 8 – 8 x 50% (ACAS) = 4
  43. 43. Allocation des ressources • Number Needed to Treat
  44. 44. Allocation des ressources • Prévalence de sténose 60-99% est de 1% • Donc 10 000 par millions d’habitants • Si 4 chirurgies par jours pour 260 jours travaillés • 9,6 ans de temps opératoire
  45. 45. Traitement médical • Utilisation des statines à haute dose – SPARCL: Diminution de 16% du risque d’AVC sur 5 ans • Contrôle tensionnel plus aggressif – Utilisation des IECA (HOPE et PROGRESS) • Utilisation des antiplaquettaires en prévention primaire • Modification du style de vie – Alimentation, tabagisme et exercice physique • Cessation de l’hormonothérapie chez la femme
  46. 46. Traitement médical Third,neitherACASnorACSTshowed thatincreasingseverityofstenosiswasan 5 years,and918(92%)ofprocedureswould stillbeunnecessary.36 Table3| Temporal changes in the 5-year stroke risk* in ACAS and ACST Trial Yearsoffollow-up Year published Any stroke(% pa) Ipsilateral stroke (% pa) ACAS3 1–5 1995 17.5 (3.5) 11.0 (2.2) ACST4 1–5 2004 11.8 (2.4) 5.3 (1.1) ACST5,37 6–10 2009 7.2 (1.4) 3.6 (0.7) *In medically treated patients. Abbreviation: pa,per annum. P E R S P E C TIV E S Third,neitherACASnorACSTshowed thatincreasingseverity ofstenosiswasan 5 years,and918(92%)ofprocedureswould stillbeunnecessary.36 Table3| Temporal changes in the 5-year stroke risk* in ACAS and ACST Trial Yearsoffollow-up Yearpublished Anystroke (% pa) Ipsilateral stroke (%pa) ACAS3 1–5 1995 17.5 (3.5) 11.0 (2.2) ACST4 1–5 2004 11.8 (2.4) 5.3 (1.1) ACST5,37 6–10 2009 7.2 (1.4) 3.6 (0.7) *In medically treated patients. Abbreviation: pa,per annum. P E R S P E C TIV E S
  47. 47. Traitement médical rereportedin skhasdimin- many of the ompromised. a systematic of stroke had hat noninter- ly safer than 8 times more strokeriskhas rovements in dicaltherapy, statintherapy ar disease. A wn that high- symptomatic 1984 0 1989 1 2 3 4 5 6 Any stroke; 50–99% stenosis Any stroke; 50–99% stenosisAny stroke; 60–99% stenosis Any stroke; 70–99% stenosis Ipsilateral stroke; 50–99% stenosis Ipsilateral stroke; 60–99% stenosis Ipsilateral stroke; 70–99% stenosis 58 Year Annualratesofstroke(%) 1994 1999 2004 2009 63 59 62 44 45 68 68 44 66 66 63 64 60 60 67 77 55 77 ACAS3 ACAS3 ACST 1–5 years4 61 54 54 ACST 6–10 years5 ACST 6–10 years5 ACST 1–5 years4 61 65 69 ACAS ‘any stroke’ ACAS ‘ipsilateral stroke’ P E R S P E C T IV E S rereportedin skhasdimin- many of the ompromised. a systematic f stroke had at noninter- ly safer than 8 times more trokeriskhas rovements in dicaltherapy, statintherapy ar disease. A n that high- symptomatic 1984 0 1989 1 2 3 4 5 6 Any stroke; 50–99% stenosis Any stroke; 50–99% stenosisAny stroke; 60–99% stenosis Any stroke; 70–99% stenosis Ipsilateral stroke; 50–99% stenosis Ipsilateral stroke; 60–99% stenosis Ipsilateral stroke; 70–99% stenosis 58 Year Annualratesofstroke(%) 1994 1999 2004 2009 63 59 62 44 45 68 68 44 66 66 63 64 60 60 67 77 55 77 ACAS3 ACAS3 ACST 1–5 years4 61 54 54 ACST 6–10 years5 ACST 6–10 years5 ACST 1–5 years4 61 65 69 ACAS ‘any stroke’ ACAS ‘ipsilateral stroke’ P E R S P E C T IV E S
  48. 48. Traitement médical
  49. 49. Traitement médical
  50. 50. Donc… • Pas de concensus • Intervention de masse ne prévient que 4% de AVC • 96% des procédures sont inutiles • Mauvais allocation des ressources – 2 billions de USD par année • Lignes directrices de l’AHA – « CEA or CAS on highly selected patients» • Mais qui sont ces patients…
  51. 51. À Risque…degré de sténose Severity of Asymptomatic Carotid Stenosis and Risk of Ipsilateral Hemispheric Ischaemic Events: Results from the ACSRS Study A.N. Nicolaides,1 , 4 * S.K. Kakkos,1 M. Griffin,1 M. Sabetai,1 S. Dhanjil,1 T. Tegos,1 D.J. Thomas,2 A. Giannoukas,1 G. Geroulakos,1 , 3 N. Georgiou,4 S. Francis,1 E. Ioannidou,4 C.J. Dore´5 and For the Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group Departments of 1 Vascular Surgery, Imperial College, 2 Neurology, St Mary’s Hospital, 3 Vascular Surgery, Ealing Hospital, London, UK; 4 TheCyprus Instituteof Neurology and Genetics, Nicosia, Cyprus; and 5 MRC Clinical Trials Unit, London, UK Objectives. This study determines the risk of ipsilateral ischaemic neurological events in relation to the degree of asymptomatic carotid stenosis and other risk factors. Methods. Patients (nZ 1115) with asymptomatic internal carotid artery (ICA) stenosis greater than 50% in relation tothe bulbdiameter werefollowed up for aperiod of 6–84 (mean 37.1) months. Stenosiswasgraded using duplex, and clinical and biochemical risk factors wererecorded. Results. Therelationship between ICA stenosisand event rateislinear when stenosisisexpressed by theECST method, but S-shaped if expressed by the NASCET method. In addition to the ECST grade of stenosis (RR 1.6; 95% CI 1.21–2.15), history of contralateral TIAs(RR 3.0; 95% CI 1.90–4.73) and creatininein excessof 85 mmol/L (RR 2.1; 95% CI 1.23–3.65) wereindependent risk predictors. Thecombination of these three risk factors can identify a high-risk group (7.3% annual event rateand 4.3% annual strokerate) and a low risk group (2.3% annual event rate and 0.7% annual stroke rate). Conclusions. Linearity between ECST per cent stenosis and risk makes this method for grading stenosis moreamenableto risk prediction without any transformation not only in clinical practice but also when multivariable analysis is to beused. Identification of additional risk factors provides a new approach to risk stratification and should help refinetheindications for carotid endarterectomy. Keywords: Asymptomatic; Carotid; Stenosis; Risk; NASCET; ECST. Introduction Thedegree of internal carotid artery (ICA) stenosis is a (ACAS).2 It hasbecome known astheNorth American, ‘NASCET’ or ‘N’ method.3 The second method expresses the residual lumen as a percentage of the Eur JVasc Endovasc Surg 30, 275–284 (2005) doi:10.1016/ j.ejvs.2005.04.031, available online at http:/ / www.sciencedirect.com on –1115 patients –Sténose de plus de 50% à l’échographie –Suivi moyen 37 mois Severity of Asymptomatic Ca Ipsilateral Hemispheric Ischaem Eur JVasc Endovasc Surg 30, 275–284 (2005) doi:10.1016/ j.ejvs.2005.04.031, available online at http:/ / www.scienced
  52. 52. À Risque…degré de sténose Severity of Asymptomatic Carotid Stenosis and Risk of Ipsilateral Hemispheric Ischaemic Events: Results from the ACSRS Study A.N. Nicolaides,1 , 4 * S.K. Kakkos,1 M. Griffin,1 M. Sabetai,1 S. Dhanjil,1 T. Tegos,1 D.J. Thomas,2 A. Giannoukas,1 G. Geroulakos,1 , 3 N. Georgiou,4 S. Francis,1 E. Ioannidou,4 C.J. Dore´5 and For the Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group Departments of 1 Vascular Surgery, Imperial College, 2 Neurology, St Mary’s Hospital, 3 Vascular Surgery, Ealing Hospital, London, UK; 4 TheCyprus Instituteof Neurology and Genetics, Nicosia, Cyprus; and 5 MRC Clinical Trials Unit, London, UK Objectives. This study determines the risk of ipsilateral ischaemic neurological events in relation to the degree of asymptomatic carotid stenosis and other risk factors. Methods. Patients (nZ 1115) with asymptomatic internal carotid artery (ICA) stenosis greater than 50% in relation tothe bulbdiameter werefollowed up for aperiod of 6–84 (mean 37.1) months. Stenosiswasgraded using duplex, and clinical and biochemical risk factors wererecorded. Results. Therelationship between ICA stenosisand event rateislinear when stenosisisexpressed by theECST method, but S-shaped if expressed by the NASCET method. In addition to the ECST grade of stenosis (RR 1.6; 95% CI 1.21–2.15), history of contralateral TIAs(RR 3.0; 95% CI 1.90–4.73) and creatininein excessof 85 mmol/L (RR 2.1; 95% CI 1.23–3.65) wereindependent risk predictors. Thecombination of thesethreerisk factors can identify a high-risk group (7.3% annual event rate and 4.3% annual strokerate) and a low risk group (2.3% annual event rateand 0.7% annual stroke rate). Conclusions. Linearity between ECST per cent stenosis and risk makes this method for grading stenosis moreamenableto risk prediction without any transformation not only in clinical practicebut also when multivariable analysis is to beused. Identification of additional risk factors provides a new approach to risk stratification and should help refinetheindications for carotid endarterectomy. Keywords: Asymptomatic; Carotid; Stenosis; Risk; NASCET; ECST. Introduction (ACAS).2 It has become known astheNorth American, 3 Eur JVasc Endovasc Surg 30, 275–284 (2005) doi:10.1016/ j.ejvs.2005.04.031, available online at http:/ / www.sciencedirect.com on
  53. 53. À Risque…Progression • 1015 patients • Suivi pour 3,2 ans • 9% de progression de sténose Schillinger Gerald Maurer, Kurt Huber, Renate Koppensteiner, Oswald Wagner, Erich Minar and Martin Schila Sabeti, Oliver Schlager, Markus Exner, Wolfgang Mlekusch, Jasmin Amighi, Petra Dick, Outcomes in Cardiovascular High-Risk Patients Progression of Carotid Stenosis Detected by Duplex Ultrasonography Predicts Adverse Print ISSN: 0039-2499. Online ISSN: 1524-4628 Copyright © 2007 American Heart Association, Inc. All rights reserved. is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Stroke doi: 10.1161/STROKEAHA.107.488387 2007;38:2887-2894; originally published online September 20, 2007;Stroke. http://stroke.ahajournals.org/content/38/11/2887 World Wide Web at: The online version of this article, along with updated information and services, is located on the
  54. 54. À Risque…Progression Schillinger Gerald Maurer, Kurt Huber, Renate Koppensteiner, Oswald Wagner, Erich Minar and Martin Schila Sabeti, Oliver Schlager, Markus Exner, Wolfgang Mlekusch, Jasmin Amighi, Petra Dick, Outcomes in Cardiovascular High-Risk Patients Progression of Carotid Stenosis Detected by Duplex Ultrasonography Predicts Adverse Print ISSN: 0039-2499. Online ISSN: 1524-4628 Copyright © 2007 American Heart Association, Inc. All rights reserved. is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Stroke doi: 10.1161/STROKEAHA.107.488387 2007;38:2887-2894; originally published online September 20, 2007;Stroke. http://stroke.ahajournals.org/content/38/11/2887 World Wide Web at: The online version of this article, along with updated information and services, is located on the
  55. 55. À Risque…Aspects cliniques • Genre – Femmes avait plus de complications préopératoires dans ACAS • Age – < 75 ans semblent avec le plus grand bénéfice – Idéalement survie >5 ans • ATCD d’évènement contralatéral – ACSRS: 3,4% vs 1,2% p<0.0001
  56. 56. À Risque…Radiologique Morphologie de la plaque à l’Échographie – Gray-Scale median • Mesure de valeur de gris des pixel de la plaque en entier • Bas: Plaque peu échogène • Haut: Plaque plus échogène • Plus les valeur sont basse, plus la plaque est à risque – Aire de la plaque • Plus l’aire est grande plus de risque de symptômes – Aire noire juxta-luminale • Représente des zones plus molles de la plaque • Proportionnel aux symptômes
  57. 57. À Risque…Radiologique Infarctus silencieux – Que veux dire symptomatique lorsque nous dormons 1/3 du temps? – Tout ICT survenant durant cette période passe inaperçu et les patients sont toujours « cliniquement asymptomatique » – Que ces patients asymptomatiques avec évidence radiologique au TDM d’infarctus silencieux sont à plus haut risque demeure un toujours un débats
  58. 58. À Risque…RadiologiqueTable III. Distribution of contralateral embolic infarction and other infarct typ infarction on computed tomography scanning Type Ipsilateral embolic infarction, No. (%) Present (n 146) Absent (n 675) Other infarct types, ipsilaterally 21 (14.4) 3 (0.4) Contralateral embolic infarction 81 (55.5) 91 (13.5) Other infarct types, contralaterally 17 (11.6) 8 (1.2) CI, Confidence interval; OR, odds ratio. a These included watershed and basal ganglia lacunesin the ipsilateral or contralateral hemisphere. 906 Kakkoset al
  59. 59. À Risque…Radiologique Détection d’embolie à l’échographie •Doppler transcranien Table 5| Studies* correlating baseline embolization with late risk of ipsilateral stroke54 Study Ipsilateral strokes in patients with embolic signals Ipsilateral strokes in patients without embolic signals OR (95% CI) ACES54 5/77 (6.5%) 5/390 (1.3%) 5.35 (1.51–18.94) Abbott et al.77 2/60 (3.3%) 4/171 (2.3%) 1.44 (0.26–8.07) Molloy & Markus78 1/12 (8.3%) 0/30 (0%) 7.96 (0.30–209.7) Orlandi et al.79 3/6 (50.0%) 0/15 (0%) 31.00 (1.29–747.03) Siebler et al.80 1/8 (12.5%) 1/56 (1.8%) 7.86 (0.44–140.14) Spence et al.81 5/32 (15.6%) 3/287 (1.0%) 17.53 (3.97–77.38) Total 17/195 (8.7%) 13/949 (1.4%) 6.63 (2.85–15.44) *Observational. Abbreviation: ACES, Asymptomatic Carotid Emboli Study. P E R S P E C T I V E S
  60. 60. À Risque…Radiologique Morphologie de la plaque à la Résonnance magnétique – Capacité de Dx rupture de cap fiberux ou hémorragie intraplaques – Quelques études avec peu de patients et sténose de bas grade ont démontré augmentation du risque d’événement – Seulement en analyse univariée – À définir
  61. 61. Qui gagnera? CEA, CAS may bean acceptablealternativeoption based on the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial [1]. FactorsInvolved in Clinical Decision Making Despite the level 1 evidence in favor of CEA in general, it is crucial torecognizethelimitationsandavoidgeneralizationor extrapolation of results. The stroke prevention benefits with CEA (or CAS) are dependent on 3 factors—the actual stroke risk if carotid revascularization isdeferred, theperiprocedural strokeor death rate, and thelifeexpectancy of theindividual. death intheanalysis[24••]. In CREST, it wasshown that stroke outcomeswith CEA weresignificantly better than CASamong individuals >70 years [25]. This is an important consideration when planning carotid revascularization in the elderly (Fig. 2). Insummary,therisk of aperiprocedural strokewithitshighcase fatality rate in the elderly and the lack of good evidence must deter clinicians from recommending carotid revascularization routinely in theelderly [26]. Rather, an individualized approach that takesinto account lifeexpectancy, functional statusand co- morbidities would beprudent (Fig. 2). The epidemiology of stroke in general is different among men and women. Women have better life expectancy but a higher strokerisk at an older agecomparedwith men[13, 27]. Fig. 2 An algorithmic approach to management of asymptomatic carotid stenosis
  62. 62. Qui gagnera?
  63. 63. Qui gagnera? • Paradoxe c’est que je n’aurais pu ni gagner ni perdre Pas gagner • Aussi longtemps que les institutions ne reconnaisse pas la baisse d’événements sous traitement médical rien de changera Pas perdre • La majorité des patients asymptomatiques n’auront jamais d’évènement
  64. 64. À Suivre… • A suivre… – SPACE-2: CEA vs CAS vs BMT – TACIT: CEA vs CAS vc BMT – CREST-2: 2 bras: CEA + BMT vs BMT CAS + BMT vs BMT
  65. 65. Conclusion • Pas de concensus mondial sur le traitement optimal des patients avec sténose asymptomatique • Les bénéfices bien que petits démontrés dans ACAS et ACST semblent présents • Trop se fier sur ces données historiques peut être inapproprié dans l’ère moderne
  66. 66. Conclusion • Intervention de masse chez les patients asymptomatiques prévient que peu d’évènements neurologiques • Plus de 90% des patients subiront des procédures non nécessaire résultant en coût pour le système important dans l’ère d’optimisation des ressources • Il existe probablement un sous-groupe de patients qui bénificierait d’une procédure mais ils demeurent à être identifié
  67. 67. «Get your facts first, and then you can distort them as much as you please. » -Mark Twain
  68. 68. Traitement médical • k
  69. 69. Considérations historiquesTable 2 | Observations that challenge the ‘one size fits all’ policy* Year Observation 1991 40% of surgeon applicants to ACAS were rejected, raising questions about generalizability 18 1995 With a 2.3% procedural risk, CEA prevented only 59 strokes at 5 years per 1,000 CEAs in ACAS3 With procedural risk included, CEA conferred no benef t in women in ACAS3 No relationship between stenosis severity or bilateral disease and late stroke risk was demonstrated in ACAS3 Even if you could treat every patient, 95% of all strokes in the community would still occur 70 1996 Hertzer concedes that annual risk of stroke in ACAS was much lower than had been expected71 Even with the procedural risk excluded, CEA still conferred no benef t in women in ACAS30 The f rst editorial to question whether the ACAS results warranted a tenfold increase in CEA numbers is published12 1997 The Canadian Stroke Consortium recommends against CEA and screening 14 2000 ACAS shows that CEA does not confer signif cant benef t in patients with contralateral occlusion35 In ACAS, 55% of late strokes were cardioembolic or lacunar; that is, the majority were not caused by ICA embolism72 2001 Procedural risks >3% following CEA repor ted in 7 of 10 US states 19 Using ACST entry criteria; the average procedural risk after CEA in 10 US states w as 5.9%19 2002 The principle investigator of NASCET obser ved that, had ACAS data been analyzed at 4 years, CEA would have conferred no benef t12 2003 European Stroke Initiative concludes that medical treatment is now probably the best option for asymptomatic patients23 In an editorial, Chaturvedi suggests that the RCTs should be repeated 13 2004 In ACST, CEA conferred no benef t in patients aged >75 years4 No association between stenosis severity or bilateral disease and late stroke risk was found in ACST4 If procedural risk was included, CEA conferred no signif cant benef t in women in ACST29 In ACST, most of the benef t was seen in patients with a prerandomization cholesterol level >6.5 mmol/l4 Using ACST inclusion criteria, the average procedural risk after CEA in 10 US states w as 5.4%20 A meta-analysis of 46 contemporary surgical studies, demonstrated that mortality was eight-times higher and death/stroke three-times higher compared with outcomes in A CAS21 41 nts, a number es conferred male sex, age of ipsilateral contralateral on of patient ated with an S3 or ACST.4,5 oup analyses ention. First T to demon- ficant benefit vention. The a significant ly if the oper- AS, however, en when the This apparent of course, be omized trials en; however, ACST were CEA confer- ent (OR1.04, 10-year data 010, females wn to derive The 10-year ged <75 years mpared with 5 P E R S P E C T I V E S
  70. 70. Considérations historiques In ACAS, 55% of late strokes were cardioembolic or lacunar; that is, the majority were not caused by ICA embolism72 2001 Procedural risks >3% following CEA repor ted in 7 of 10 US states 19 Using ACST entry criteria; the average procedural risk after CEA in 10 US states w as 5.9%19 2002 The principle investigator of NASCET obser ved that, had ACAS data been analyzed at 4  years, CEA would have conferred no benef t12 2003 European Stroke Initiative concludes that medical treatment is now probably the best option for asymptomatic patients23 In an editorial, Chaturvedi suggests that the RCTs should be repeated 13 2004 In ACST, CEA conferred no benef t in patients aged >75 years4 No association between stenosis severity or bilateral disease and late stroke risk was found in ACST4 If procedural risk was included, CEA conferred no signif cant benef t in women in ACST29 In ACST, most of the benef t was seen in patients with a prerandomization cholesterol level >6.5 mmol/l4 Using ACST inclusion criteria, the average procedural risk after CEA in 10 US states w as 5.4%20 A meta-analysis of 46 contemporary surgical studies, demonstrated that mortality was eight-times higher and death/stroke three-times higher compared with outcomes in A CAS21 2005 92% of all carotid revascularizations in the USA were performed in asymptomatic patients41 2007 The US Preventive Services Task Force recommends against screening for carotid artery stenosis (benef ts too low and do not outweigh risks)73 The annual risk of stroke in medically treated patients had been decreasing over the past 20 years16 2008 High-dose statin therapy stabilizes asymptomatic carotid plaques 42 Even with 15-year follow-up, CEA is not cost-effective in asymptomatic females, irrespective of age31 In an NEJM poll, 50% of respondents worldwide would treat asymptomatic patients conservatively24 Abbott suggests that it might be time to stop inter vening in asymptomatic patients15 If the procedural risk of death or disabling stroke exceeded 2.1%, or if the annual rate of fatal or disabling stroke was <1.09%, neither CEA nor CAS would not confer any long-term benef t in asymptomatic patients74 2009 A systematic review shows that noninterventional therapy is safer (attributed to improvements in medical therapy) and 3–8 times more cost-effective than CEA or CAS 16 In the USA, 94% of CEA and CAS procedures w ere ultimately unnecessar y, costing $2.1 billion per year37,40 Evidence of sustained decline in annual stroke risk in medically treated patients in ACAS and ACST37 2010 High-dose statin therapy shown to signif cantly reduce spontaneous embolization 43 A meta-analysis of three studies (1,635 patients) shows that ipsilateral stroke risk is now only 0.5% per year75 More calls issued for RCTs comparing CEA with CAS to include a third medical arm37,76 ACST 10-year data show that ARR in stroke with CEA is only 4.6% at 10  years (0.46% per year5 ) 2011 A post-CREST evaluation shows that the evidence for intervening in asymptomatic carotid artery disease is weak and CAS should not be offered until better e vidence is available25 nly if the oper- CAS, however, en when the This apparent , of course, be omized trials en; however, ACST were CEA confer- dent (OR 1.04, 10-year data 2010, females wn to derive 5 The 10-year ged <75 years ompared with cally,5 which reduction in 0.58% reduc- will question n in stroke is nal guidelines nefits of CEA he data clearly benefit from y selecting all rs is probably ost-effective31 orts to deter- will gain the ention. w that patients icant benefit d not provide mit for inclu- showed that, was excluded, patients aged ult of ACST e reserved for

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