Alma Mater Studiorum Università di Bologna

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1 Alma Mater Studiorum Università di Bologna S.Orsola-Malpighi, Bologna, Italia Chirurgia Vascolare The volume of cerebral ischaemic lesion predicts the outcome after symptomatic carotid revascularisation A Stella

2 Alma Mater Studiorum Università di Bologna S.Orsola-Malpighi, Bologna, Italia Chirurgia Vascolare Nothing to disclose A Stella

3 Clinical case:, 78 years-old Right hemispheric ischemic minor - stroke Risk factors Right carotid artery stenosis 90% Contralateral carotid occlusion Hypertension COPB Coronary artery disease

4 Clinical case:, 78 years-old Cerebral CT at 24 and 48 hours Cerebral ischemic lesion: diameter 1,5 cm Neurological stability (NHISS = 8)

5 Clinical case:, 78 years-old Cerebral CT at 24 and 48 hours Cerebral ischemic lesion: diameter 1,5 cm Neurological stability (NHISS = 8) Referred to carotid revascularization after a new cerebral CT control at 7 days

6 Clinical case:, 78 years-old After 4 days New major ischemic stroke (NHISS=15)

7 Clinical case:, 78 years-old After 4 days: New major ischemic stroke (NHISS=15) What is the risk /benefit for carotid revascularization in patients with acute cerebral ischemic lesions? Early surgery or not?

8 Rischio di stroke (%) Stroke risk (%) Background Early carotid revascularization is recommended after neurologic events to avoid new strokes Giorni Days Rothwell, Lancet Neurol 2006

9 Post-op stroke % Summary of Evidence on Early Carotid Intervention for Recently Symptomatic Stenosis Based on Meta-Analysis of Current Risks De Rango et al, Stroke 2015 Timing of surgery influence the post operative outcome Preoperative symptoms

10 Post-op stroke % Background Outcomes of carotid revascularization 20% Why high inter-studies variability? 0% De Rango et al, Stroke 2015

11 Background Usually the Studies do not report cerebral imaging status (morphology of the cerebral lesion) Frequently the patient have not serious neurological status (NHISS <15)

12 Can the aspect and volume of cerebral ischemic lesions predict the carotid revascularization otcome?

13 Vascular Annual Meeting 2016, Washington

14 Methods Retrospective evaluation of all patients submitted to carotid revascularization by carotid endarterectomy or stenting for symptomatic carotid artery stenosis ( )

15 Methods Pts with Cerebral Ischemic Lesion (CIL) Preoperative computed tomography (CT) Ipsilateral Embolic (Steven s Classification) Volume evaluation (mm 3 ) multi-planar evaluation

16 Volume: an easy calculation ABC/2 for rapid clinical estimate of infarct, perfusion, and mismatch volumes Sims et al. Neurology 2009

17 Results Revascularization n % Patients 489 CEA CAS Symptoms TIA Stroke < 15 days Cerebral Ischemic Lesion 51.4% (#251)

18 Results: preoperative characteristics CIL % No CIL% P Age > 80 years Male sex Hypertension Dyslipidemia Diabetes mellitus Smoke Coronary artery disease COPD Chronic renal failure Atrial fibrillation Contralateral carotid occlusion

19 Results: preoperative characteristics CIL No CIL P Clinical presentation % (n: 251) % (n: 238) Stroke TIA weeks

20 Results: revascularization outcome Stroke % P Stroke/Death % All population Type of revasc CEA (327) CAS (162) P.22

21 Results: revascularization outcome Stroke % P Stroke/Death % All population Type of revasc CEA (327) CAS (162) Timing 2 weeks (186) > 2 weeks (303) P.22.26

22 Results: revascularization outcome Basic evaluation of ischemic Infarct Post-op stroke % P= Positive (251) Negative (238)

23 Results: revascularization outcome Basic evaluation of ischemic Infarct Post-op stroke % The presence of a cerebral ischemic lesion did not influence P=.47 the outcome 3.5 Positive (251) Negative (238)

24 Results: CIL volume evaluation 1000 (7000) 5100 (31000) P=.01 No events postop stroke Median volume: 1000 mm 3 (IQR 7000mm 3 )

25 Results: CIL volume evaluation ROC curve CIL-vol>4000mm 3 Area =.68 P =.02 Sensitivity =.75 Specificity =.63 Youden J statistic

26 Results: CIL volume evaluation ROC curve CIL-vol>4000mm 3 CIL-vol> 4000mm 3 significant predictor for stroke Area =.68 P =.02 Sensitivity =.75 Specificity =.63 Youden J statistic

27 % Results: CIL-vol 4000 mm 3 P=.01 OR: % CI:

28 CIL Volume >4000mm 3 is an Independent risk factor Multivariate Analysis OR 95% CI P Age Contralateral carotid occlusion Timing of revascularization Type of revascularization CIL Volume > 4000 mm Sex Diabetes mellitus

29 Literature review: CIL effect on carotid revascularization Authors N Pts Risk Factor No Risk Factor Cao et al X Blohme et al X Bond et al X Faggioli et al X

30 Conclusion The presence of Ischemic Cerebral Lesion(CIL) does not affect CEA/CAS outcomes, but a CIL volume >4000 mm 3 produce higher post-operative stroke risk

31 Conclusion The cerebral damage needs to be investigated for the emergency carotid revascularization for risk stratification

32 Prospective Patient with CIL< 4000 mm 3 can be revascularized without significant higher perioperative risk

33 Implications CIL> 4000 mm 3 higher risk (9%) independently from timing High risk stenosis (ABCD 2 -score): Early revascularization? Low risk stenosis: Wait and see?

34 Alma Mater Studiorum Università di Bologna S.Orsola-Malpighi, Bologna, Italia Chirurgia Vascolare The volume of cerebral ischaemic lesion predicts the outcome after symptomatic carotid revascularisation A Stella