1. Lack of evidence in carotid stenosis management
Pascual Lozano Vilardell
Angiología y Cirugía Vascular
Mallorca
ESVS-SEACV Joint Session
58 Congreso Nacional SEACV Barcelona 2012

2. Lack of evidence in symptomatic patients

3. When should we intervene after an ischemic stroke?

4. 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

5. When should we intervene after an ischemic stroke?
Urgent CEA in unstable patients
Stroke in evolution 20,2%
Crescendo TIA 11,4%
Early CEA in stable patients with TIA/minor stroke
<2 weeks 1,2%
CEA in stable major nondisabling stroke ?
Rerkasem K et al. Systematic review of operative risk of CEA for recently symptomatic stenosis.
Stroke 2009;40:e564-e572

6. When should we intervene after an ischemic stroke?
1158 CEAs in TIA/minor stroke
Stroke post CEA:
< 4 weeks 5.1%
> 4 Weeks 1.6% p 0.002
Rockman CB et al. Early carotid endarterectomy in symptomatic patients is assocoated with poorer
outcomes. J Vasc Surg 2006;44:480-7

7. When should we intervene after an ischemic stroke?
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%
GALA trial. Lancet 2008;372:2132-2142

8. CEA/CAS and coronary surgery

9. CEA/CAS and coronary surgery
Combined CEA-CABG
Both symptomatic
Staged CEA or CAS
Coronary 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

10. CEA/CAS and coronary surgery
30 days death/stroke
CEA 10,0% (Staged = combined)
30 days death/stroke
CAS 9,1% (asymptomatic)
Naylor et al. Eur J Vasc Endovasc Surg 2003;25:380-9
Naylor et al. Eur J Vasc Endovasc Surg 2009;37:379-87

11. Lack of evidence in carotid stenosis management
SYMPTOMATIC CAROTID STENOSIS
Probably we should intervene early
We don’t know what to do in combinated lesions

12. Lack of evidence in asymptomatic patients

13. Are the results of ACAS and ACST out of date?

14. Are ACAS and ACST out of date?
5 year risk CEA BMT RRR NNT
ACAS 5,1% 11,0% 54% 84
ACST 6,4% 11,8% 46% 70
10 year risk
ACST 13,4% 17,9% 26%
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

15. 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%

16. Are ACAS and ACSTACST out
Are ACAS and obsolete? of date?
2008
Klein A et al. Management of carotid stenosis- polling results. N Eng J Med 2008,358:e23

17. Are ACAS and ACST out of date?

18. Are ACAS and ACST out of date?
Marginal surgical benefit (ARR 1%)
Patient selection
Nature of intervention
Results “in the real world”
Neurological auditories
Rol of CAS
Increased evidence for Best Medical Treatment
Aggresive medical management
Healthy 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

19. What is the risk of stroke in ACS right now?

20. What is the risk of stroke in Asymptomatic Carotid Stenosis?
8,71%
4,04%
Hong K et al. Declining Stroke and Vascular Events Recurrence Rates in Secondary Prevention Trials.
Circulation 2011;123:2111-2119

21. 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

22. What is the risk of stroke in Asymptomatic Carotid Stenosis?
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

23. What is the risk of stroke in Asymptomatic Carotid Stenosis?
ipsilateral stroke any stroke
Abbott AL. Medical intervention alone is now best for prevention of stroke associated with
asymptomatic severe carotid stenosis. Stroke 2009;40:573-583

24. What is the risk of stroke in Asymptomatic Carotid Stenosis?
3,5%
2,4%
1,4%
2,2%
1,1% 0,7%
any stroke ipsilateral stroke
Naylor AR. What is the current status of invasive treatment of extracraneal carotid artery disease?
Stroke 2011;42:2080-85

25. What is the risk of stroke in Asymptomatic Carotid Stenosis?
OXFORD VASCULAR STUDY (2002-2009)
1200 patients with TIA / stroke
101 patients with ACS intensive MT
Annual ipsilateral stroke rate 0,34%
Marquardt L et al. Low risk of ipsilateral stroke in patients with ACS on best medical treatment.
Stroke 2010;41:11-17

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

27. There are patients at high stroke risk?
Can we identify this patients?
Clinical features Microembolism
Degree of stenosis Silent infarcts
Progression of stenosis Biomarkers
Plaque characteristics
Cerebrovascular reactivity

28. There are asymptomatic patients at high risk of stroke?
Clinical features
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)
Hirt LS. Stroke. 2011;42
Nicolaides AN et al. Eur J Vasc Endovasc Surg. 2005;30:275-284

29. There are asymptomatic patients at high risk of stroke?
Degree of stenosis
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)
Kakkos SK et al. J Vasc Surg 2009;49:902-9
Rijbroek A et al. Eur Neurol 2006;56:139-154

30. 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

31. There are asymptomatic patients at high risk of stroke?
Carotid plaque vulnerability: MICROEMBOLISM
Jayasooriya G et al. J Vasc Surg 2011;54:227-36

32. There are asymptomatic patients at high risk of stroke?
Carotid plaque vulnerability: MICROEMBOLISM
Patients with MES Mean number MES
10% 2,63 (1-20)
ipsilateral stroke
MES 3,62%
No MES 0,70%
Markus HS et al. Asymptomatic embolisation for prediction of stroke in the ACES: a prospective
observational study. Lancet Neurol 2010;9:663-671

33. There are asymptomatic patients at high risk of stroke?
Carotid plaque vulnerability: MICROEMBOLISM
468 patients with ACS > 70%
Patients with MES Carotid plaque Cardiovascular
progression events
2000-2002 12,6% 69 mm2 17,6%
2003-2007 3,7% 23 mm2 5,6%
Intensive medical therapy
Spence JD et al. Effects of Intensive Medical Therapy on Microemboli and Cardiovascular Risk in ACS.
Arch Neurol 2010;67:180-86

34. There are asymptomatic patients at high risk of stroke?
COMBINATION SCORES: ACES
ipsilateral stroke
Echolucency + MES 8,90%
None 0,80%
Topakian R et al. Neurology 2011;77:751-758

35. There are asymptomatic patients at high risk of stroke?
COMBINATION SCORES: ACSRS
a)Stenosis alone: 0.59
b)Stenosis + clinical features (smoking, contralateral stroke/TIA): 0.66
c)Stenosis + plaque characteristics + previous contralateral TIA/stroke: 0.82
Nicolaides AN et al. ACS and cerebrovascular risk stratification. J Vasc Surg. 2010;52:1486-96

36. There is place for angioplasty in ACS?

37. There is place for angioplasty in ACS?
CREST ASYMPTOMATIC periprocedural 4 years
CEA 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

38. There is place for angioplasty in ACS?
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

39. Lack of evidence in carotid stenosis management
ASYMPTOMATIC CAROTID STENOSIS
ACAS and ACST results are being questioned
We don’t know the exact risk of stroke of ACS
Probably there are patients at very low stroke risk
Probably there are patients at high stroke risk
We don’t have standardized methods to identify this patients
Probably no place for rutinary CEA or CAS in ACS

40. So we need more RCT in
Asymtomatic Carotid Stenosis