Prise en charge du polyvasculaire

Transcription

1 Prise en charge du polyvasculaire Dépistage et prise en charge des sténoses carotidiennes Serge Kownator Centre cardiologique et Vasculaire - Thionville

2 Disclosure Statement of Financial Interest I currently have, or have had over the last four years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Grant/Research Support Consulting Fees/Honoraria Affiliation/Financial Relationship Company Astra Zeneca, Bayer Amgen, Bayer, Boehringer Ingelheim, Daiichi Sankyo, MSD, Sanofi, Philips. Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Other Financial Benefit none none none none none

3 Should we screen for carotid stenosis? AMERICA Study JP Collet et al. ESC 2016

4 Primary Endpoint at 2 years-fu* * death, any ischemic event leading to rehospitalization or any evidence of organ failure

5 Outcomes

6 What Means Carotid Stenosis? Method of grading B 6

7 Prevalence of serious carotid stenosis > 50% = 4.2% (CI, 3.1%-5.7%) > 70% = 1.7% (CI, 0.7%-3.9%) Adults over 70 years: 6.9 % in women 12.5 % in men (incl. occlusion) ACS in CAD: Average prevalence of.50,.60,.70, and.80% carotid stenosis was reported in 14.5, 8.7, 5.0, and 4.5% of patients Moderate Severe de Weerd M et al. Stroke. 2009;40: Stroke Jun;41(6): Aboyans V et al. Presse Med 2009;38:

8 Circonstances du diagnostic Patients sans symptômes dans le territoire de la sténose = STENOSE CAROTIDIENNE ASYMPTOMATIQUE Patients avec des symptômes dans le territoire de la sténose = STENOSE CAROTIDIENNE SYMPTOMATIQUE Dépistage chez des patients ayant une maladie vasculaire: coronaires, membres inférieurs, aorte Dépistage chez les diabétiques Infarctus ou AIT dans un autre territoire Infarctus cérébral ou AIT dans le territoire de la sténose <6-12 mois Infarctus cérébral ou AIT dans le territoire de la sténose >6-12 mois

9 Prediction of asymptomatic carotid stenosis De Weerd et al. Stroke Aug; 45(8):

10 Asymptomatic carotid stenosis Morbi/mortality relates mostly on CHD Cause of death in patients with ACS (meta analysis)*:, 11,391 patients with ACS > 50%: 17 studies: 5-yrs all cause mortality = 23,6% 12 studies: cardiac mortality = 2.9 % per Yr ** *Giannopoulos A et al. Eur J Vasc Endovasc Surg (2015) 50, 573e582 **Divya KP et al. J Stroke Cerebrovasc Dis Sep;24(9):

11 Screening for carotid stenosis in asymptomatic patients! Physical examination High risk patients: LEAD Coronary artery disease CABG (or other cardiac or vascular surgery)

12 Physical examination Carotid bruit? Northern Manhattan Study (NOMAS): 686 subjects with a mean age of 68.2 ± 9.4 years Prevalence of carotid bruit: 4.1 % DUS => 2.2% carotid stenosis 60% Sensitivity of auscultation : 56% Specificity 98%, PPV: 25% - NPV: 99% Accuracy was 97.5%. 44% false-negative rate suggests that auscultation is not sufficient to exclude carotid stenosis. Ratchford EV et al. Neurol Res September ; 31(7):

13 Imaging DUS - commonly used as the first step to detect extracranial carotid artery stenosis and to assess its severity CTA - widely available and allows for a differenciation between ischaemic and haemorrhagic stroke MRA - more sensitive in the detection of brain ischaemia European Heart Journal (2011) 32,

14 CABG: a model for polyvascular disease! Carotid Artery Screening European Heart Journal (2014) 35,

15 ACS detected before CABG Aboyans in Pan Vascular Medicine 2014

16 Stroke and CABG European Heart Journal (2014) 35,

17 CABG and Carotid stenosis European Heart Journal (2014) 35,

18 Stroke and CABG European Heart Journal (2014) 35,

19 What if Asymptomatic Carotid Stenosis Detected Prior to CABG is not Operated? 90% of peri-operative stroke cases during CABG are not related to the carotid stenosis (including carotid occlusion). Li et al, Arch Neurology 2009 In several small series (n=100) of patients undergoing CABG without intervention on their asymptomatic carotid stenosis, the reported rates of stroke are 0%! Courtesy V Aboyans. Ghosh et al, Eur J Vasc Endovasc Surg 2005 Manabe et al, Eur J Vasc Endovasc Surg 2008 Nakamura et al, Ann Thorac Surg 2008 Baiou et al, Eur J Vasc Endovasc Surg 2009

20 ESC Guidelines on the diagnosis and treatment of peripheral artery diseases Algorithm for the management of extracranial carotid artery disease Tendera M, Aboyans V et al. Eur Heart J Nov;32(22):

21 Carotid endarterectomy for ACS Studies and meta analysis Chambers et al. Cochrane Database Syst Rev Oct 19;(4) Guay J et al. J Cardiothorac Vasc Anesth Oct;26(5):

22 3110 patients NTH (1 month) Stroke/periop death : 34 NTT (5 years) Stroke/ periop death : 24 Stroke/all death : 77

23 The annual risk of ipsilateral stroke has decreased Ipsi stroke: 2.2% Ipsi stroke: 1.1% Ipsi stroke: 0.7% Naylor AR. Stroke. 2011;42:

24 The challenge! Can we identify a group of patients with > 60% asymptomatic carotid stenosis in whom surgery can offer a clear benefit and thus treating all the other with best medical therapy? The candidate parameters: 1. Clinical features 2. Plaque characterization Echogenicity with US, Intraplaque hemorrhage, thin fibrous plaques, necrotic core with MR or CT Surface Neo vascularization inflammation 3. Progression of the stenosis 4. Downstream consequences Hemodynamic impairment cerebral vasoreactivity Distal Embolization..

25 Longstreth WT et al Stroke 1998;29: Liapis CD et al. Stroke. 2001;32: Asymptomatic carotid stenosis Daily Practice Despite recommendation, screening is part of daily practice! Best medical treatment for all! Antiplatelet therapy Statin : LDL C < 70 mg/dl BP control : <140/90 mmhg Consider Intervention with the integration of the different parameters: CEA or CAS? Waiting for new studies : ACST 2, CREST 2, ACTRIS.. Waiting for new Guidelines

26

27 Who may not be selected for CEA? Mortality risk after revasc. for patients with asymptomatic carotid stenosis: the Carotid Risk Assessment Tool (CARAT) Faerber et al. BMC Medical Informatics and Decision Making (2015) 15:20)

28 Clinical Parameters Factors independently associated with an increased risk of stroke in patients with asymptomatic carotid stenosis Gender* Age* Systolic blood pressure, Increased serum creatinine, Smoking history of more than 10 pack-years, History of controlateral transient ischemic attacks (TIAs) or stroke* Controlateral carotid occlusion* Nicolaides AN. J Vasc Surg 2010;52:

29 Plaque Characterization Ultrasound Plaque Echolucency and Stroke Risk in Asymptomatic Carotid Stenosis 7 studies on 7557 subjects with a mean follow-up of 37.2 months. Significant positive relationship between predominantly echolucent of future ipsilateral stroke in subjects with 50% stenosis (relative risk, 2.61; 95% Cl, ; p =0.001). Plaque echolucency provides predictive information in asymptomatic carotid artery stenosis The magnitude of the increased risk is not sufficient to identify patients likely to benefit from surgical revascularization Gupta A et al. Stroke. 2015;46:91-97.

30 Juxtaluminal hypoechoic area 1121 patients with asymptomatic carotid stenosis 50% to 99% The size of juxtaluminal hypoechoic area in ultrasound images of asymptomatic carotid plaques predicts the occurrence of stroke Kakkos SK et al. J Vasc Surg 2013;57:609-18

31 Surface of the plaque Regular or irregular? Smooth, irregular, ulcerated? The Northern Manhattan Study 1939 stroke-free subjects Irregular plaque surface increased IS risk nearly 3- fold Prabhakaran et al. Stroke. 2006; 37:

32 Surface of the plaque The Northern Manhattan Study 1939 stroke-free subjects Irregular plaque surface increased IS risk nearly 3-fold Bilateral plaque surface irregularity increase the risk more than unilateral irregular surface with contralateral regular surface Prabhakaran et al. Stroke. 2006; 37:

33 Progression of the degree of luminal stenosis Fast progression of carotid luminal narrowing (6- to 9-month) => increased risk of future ipsilateral neurological events and risk of midterm clinical adverse events of atherosclerosis Progression free Sabeti S et al. Stroke. 2007;38: Hirt LS et al. Stroke. 2014;45:

34 Downstream consequences Micro embolic signals - HITS 482 asymptomatic ACES study patients Carotid Stenosis 70% 16% HITS TIA 26 Stroke 6+4 HR=2.39 ( ) HR=5.90 ( ) N=10 Markus HS et al. Lancet Neurol 2010; 9:

35 Downstream consequences Silent brain infarct and neurological events 821 patients with ACS monitored every 6 months for a maximum of 8 years Stenosis <60%: Embolic Infarct not associate with the risk of neurological event Stenosis 60-99% Risk relates to Silent Embolic Infarct 2.4vs 4.6% annual event rate (P=0.032) Kakkos et al. J Vasc Surg 2009;49:903-9

36 RISK Score Prediction of annual risk of stroke in patients with 50-79% or 80-99% ACS AR Naylor, 2011, Nature Reviews Cardiology pp. 116e24.

37 Who may benefit from revascularization? Men < 80 yr with % carotid stenosis And? Controlateral occlusion History of controlateral Stroke/TIA Hypoechoeic irregular plaque Progressive higher degree of stenosis HITS at TCD Infarction at cerebral imaging Longstreth WT et al Stroke 1998;29: Liapis CD et al. Stroke. 2001;32: