Review of current issues in carotid surgery, Malta, 2014

1. Sean Tierney
Dean of Professional Development & Practice RCSI
Consultant Vascular Surgeon
Carotid diseaseCarotid disease

2. Case presentationCase presentation
History
• 62 year old 
• 6 hours ago
• Transient (R) arm
weakness
• Fully resolved within 2
hrs
• No sequelae
PMHx
• Cigs 20 pack year
• No meds

3. Brain attack – the urgencyBrain attack – the urgency
Copyright ©2004 BMJ Publishing Group Ltd.
Coull, A J et al. BMJ 2004;328:326
7% @ 1 week
10% @ 1 month
≅15% @ 1 month

4. Case presentationCase presentation
Physical examination
Systematic
• Neurological
• Cardiovascular
Head to toe
Relevant positive
and negative findings

5. Case presentationCase presentation
Differential diagnosis
History
Differential
diagnosis
Examination
Review differential
diagnosis
Investigation
Treat
Review differential
diagnosis
Evaluate
response

6. Key questionsKey questions
• Is there a stroke?
• Is it haemorrhagic or
ischaemic?
• Where might the source
be?

7. InvestigationsInvestigations
• Is there a stroke?
• Is it haemorrhagic or
ischaemic?
• Where might the source
be?
• Clinical
• CT Brain
• MRI
• DW-MRI (Timing)

8. InvestigationsInvestigations
• Is there a stroke?
• Is it haemorrhagic or
ischaemic?
• Where might the source
be?
• CT Brain
• MRI

9. InvestigationsInvestigations
• Is there a stroke?
• Is it haemorrhagic or
ischaemic?
• Where might the source
be?
• Duplex carotids
– MRA
– CTA
– (angiography)
• Echocardiography
– TTE
– TOE
• Holter

10. DuplexDuplex
• Degree of
stenosis
• ? criteria
• ? reliability
• Nature of plaque
• Position of
bifurcation
Left ICA
80-90% stenosis
Left ICA
80-90% stenosis

11. Current recommendationsCurrent recommendations
Chappell et al Radiology 2009
Contrast enhanced magnetic resonance angiography
(CEMRA)
• offered the best sensitivity and specificity
• limited by cost & accessibility
Non-invasive imaging
• accuracy is highest in patients with 70–99% stenoses
and less with 50–69% stenoses
?double scanning

12. InvestigationsInvestigations
• Is there a stroke?
• Is it haemorrhagic or
ischaemic?
• Where might the source
be?
• Is the patient a suitable
candidate for surgery?
• Co-morbidity
• Consent

14. The ContextThe Context
Naylor. The Surgeon 2009

15. Evidence based medicineEvidence based medicine
• I Meta-analysis & systematic reviews
• II Randomised Control Trial
• III Case control (non-randomised)
• IV Retrospective, cross-sectional
• V Expert opinion, descriptive studies
FFact
OOpinion
GGossip
Sackett et al. 1996 Br Med J

17. ECST outcomesECST outcomes
Ipsilateral major stroke + operative major
stroke or death ECST

18. OutcomeOutcome
High Moderate Low
Surgery 7.50% 12.70% 12.70%
Control 13.70% 17.90% 11.40%
OR (95% CI) 0.48 (0.33-0.70) 0.69 (0.51-0.94) 1.23 (1.00-1.51)
RRR 48% 27% -20%
NNT 15 21 45
Death/disabling stroke (2-6 years follow up)
Cina C et al. Cochrane Database of Systematic Reviews 1999. (accessed 2010)

19. ConclusionConclusion
Surgery reduces the risk of stroke in those with
moderate or high grade carotid stenosis provided
30 day stroke and death rate <6%
Symptomatic disease
Cina C, Clase C, Haynes RB. Carotid endarterectomy for symptomatic carotid
stenosis. Cochrane Database of Systematic Reviews 1999, Issue 3. Art. No.:
CD001081. DOI: 10.1002/14651858.CD001081

20. ChoicesChoices

21. ChoicesChoices

22. Carotid endarterectomyCarotid endarterectomy
www.acssurgery.com Stroke and Transient Ischemic Attack. TS Maldonado, TS Riles

23. Carotid endarterectomyCarotid endarterectomy
www.acssurgery.com Stroke and Transient Ischemic Attack. TS Maldonado, TS Riles

24. Carotid endarterectomyCarotid endarterectomy
www.acssurgery.com Stroke and Transient Ischemic Attack. TS Maldonado, TS Riles

25. Technical concernsTechnical concerns
• Anaesthesia
– No proven difference
• Eversion vs standard
– No proven benefit
• Shunting/monitoring
– No proven difference
• Patching
– Less recurrence

26. Postoperative carePostoperative care
• Neurological status
• Blood Pressure
• Wound issues

27. Lipsett et al J Vasc Surg 1994

28. Neurological statusNeurological status
• Alert
• Speech
• Limb movement
• Premorbid state
Concerns
• Stroke
• Cerebral oedema

29. Blood pressureBlood pressure
• + 10% preop blood
pressure
• Intravenous agents
may be required
• Hypoperfusion
• Hyperperfusion
syndrome

30. Wound problemsWound problems
• Haematoma
• Usually early
• + Swelling
• Distended veins
• Stridor
• Surgical review

31. Day 1+Day 1+
• Diet
• Mobilise
• Home by day 3-5
• ? Day 2

32. PostoperativelyPostoperatively
• Risk Factor
modification
• Aspirin
• Statin
• BP control

33. Case #2Case #2
History
• 64 year old 
• Hypertension
• Hyperchlesterolaemia
• “Routine carotid scan”
PMHx
• Cigs 20/day
• Thiazide, ACE
inhibitor, Statin
• Coronary angioplasty 4
years previously
Examination
• No bruit
• I II nil added

34. InvestigationsInvestigations
70-80% stenosis70-80% stenosis LV hypertrophy
EF 45%
LV hypertrophy
EF 45%

35. EvidenceEvidence
MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative
Group.
The Lancet 2004

36. ConclusionConclusion
I
Chambers BR, You RX, Donnan GA The Cochrane Library, 2004.

37. Time moves on…Time moves on…

38. Time marches on…Time marches on…
Naylor The Surgeon 8(2010);79–86.

39. Better medical therapyBetter medical therapy
Abbott Stroke 2009

40. Better medical therapyBetter medical therapy
Abbott Stroke 2009
… BMT is now three to eight times
more cost-effective than CEA/CAS (in
terms of stroke prevention)…
… BMT is now three to eight times
more cost-effective than CEA/CAS (in
terms of stroke prevention)…

41. …… and better…and better…
The average annual event rates on medical
treatment were 0.34% (95% CI, 0.01 to
1.87) for any ipsilateral ischemic stroke …
The average annual event rates on medical
treatment were 0.34% (95% CI, 0.01 to
1.87) for any ipsilateral ischemic stroke …
Marquardt Stroke 2010

42. Patient selectionPatient selection
Plaque morphologyEnd organ effects

43. Patient selectionPatient selection
Plaque morphologyPlaque activity

44. Plaque activityPlaque activity
• 482 patients (asymptomatic carotid stenosis >70%), 467 had TCD
• +ve TCD (emboli 77/467)
• increase in risk in +ve at 2 years
• ipsilateral stroke and transient ischaemic attack from baseline 2·54
(95% CI 1·20–5·36; p=0·015).
•ipsilateral stroke alone 5·57 (1·61–19·32; p=0·007).
•absolute annual risk of ipsilateral stroke was 3·62% in patients with
embolic signals and 0·70% in those without.

45. Asymptomatic carotid stenosisAsymptomatic carotid stenosis
??

46. Carotid stenting4

47. Carotid angioplastyCarotid angioplasty

48. Carotid stentingCarotid stenting
44

49. Carotid stentingCarotid stenting
44
• 13 randomised trials
• 7477 patients
• October 11, 2010
Bangalore et al Arch Neurol 2010

50. CAS trialsCAS trials
Bangalore et al Arch Neurol 2010

51. Procedure outcomeProcedure outcome
Bangalore et al Arch Neurol 2010
Periprocedural death, stroke or MI

52. Long term resultsLong term results
Periprocedural death, stroke or ipsilateral stroke on f/up
Bangalore et al Arch Neurol 2010

53. SummarySummary
Carotid artery stenting was associated with an
•↑ periprocedural outcomes of death, MI, or stroke
(odds ratio = 1.31; 95% confidence interval, 1.08-1.59)
•↑ 65% and 67% in death or stroke and any stroke,
respectively
•↓55% and 85% reductions in the risk of MI and cranial
nerve injury, respectively, when compared with CEA.
Bangalore et al Arch Neurol 2010

54. SummarySummary
Similarly, CAS was associated with (RR vs
CEA) in longer term follow-up:
– ↑19% periprocedural death or
– ↑ 38% stroke and ipsilateral stroke thereafter,
– ↑ 24% death or any stroke,
– ↑ 48% any stroke
Bangalore et al Arch Neurol 2010

55. Carotid stentingCarotid stenting
• CAS was associated with an increased risk of both
periprocedural and intermediate to long-term outcomes, but with
a reduction in periprocedural MI and cranial nerve injury.
Strategies are urgently needed to identify patients who are best
served by CAS vs CEA.
• CAS was associated with an increased risk of both
periprocedural and intermediate to long-term outcomes, but with
a reduction in periprocedural MI and cranial nerve injury.
Strategies are urgently needed to identify patients who are best
served by CAS vs CEA.
Bangalore et al Arch Neurol 2010

56. Carotid stenting vs endarterectomyCarotid stenting vs endarterectomy
Ederle J, Featherstone R, Brown MM. Percutaneous transluminal angioplasty and
stenting for carotid artery stenosis. Cochrane Database of Systematic Reviews 2007,
Issue 3. Art. No.: CD000515. DOI: 10.1002/14651858.CD000515.pub3

57. 5 Timing

58. IntervalsIntervals
Copyright ©2004 BMJ Publishing Group Ltd.
Coull, A J et al. BMJ 2004;328:326
7% @ 1 week
10% @ 1 month
≅15% @ 1 month
55

59. EndarterectomyEndarterectomy
• Carotid endarterectomy trialists
collaboration (CETC)
• Reanalysed all carotid RCT data
• Standardised measurements
• Rothwell et al Lancet 2004

60. DelayDelay
• No of strokes saved per 1000 CEA for symptomatic carotid
stenosis (CETC re-analysis) Rothwell et al 2004

61. Who is at risk..?Who is at risk..?
Naylor. The Surgeon 2010

62. Best practiceBest practice
Patients with TIA/minor stroke should be
• seen as soon as possible in dedicated (daily)
open access clinics that offer single visit
imaging.
• all patients should start taking their risk factor
medications as soon as possible (Express
study)
• Patients with a 50–99% ipsilateral ICA
stenosis should be admitted to the Vascular
Unit for corroborative (duplex) imaging and
expedited surgery.
Naylor. The Surgeon 2010

63. RealityReality
Naylor. The Surgeon 2010

64. RealityReality
Naylor. The Surgeon 2010
UK Carotid Endarterectomy Audit (2009)…
only 20% of patients underwent surgery within
14 days of symptom onset.

65. • Appropriate treatment
• Correct operation
• Right patient
• Right time
• Technical accuracy
• Postoperative care

66. • Appropriate treatment
• Correct operation
• Right patient
• Right time
• Technical accuracy
• Postoperative care
www.perfuse.netwww.perfuse.net
@theseant@theseant
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