Asymptomatic Carotid Artery Stenosis
|
|
- Candice Griffin
- 5 years ago
- Views:
Transcription
1 Asymptomatic Carotid Artery Stenosis Testing for plaque instability, microemboli, hemodynamic status, and cognitive function may help determine best practice management. By Randolph S. Marshall, MD, MS Introduction Carotid artery stenosis accounts for 8% to 15% of acute stroke, 1 the importance of which is magnified by the high rate of early recurrence after an initial event, up to 21% at 2 weeks and 32% at 12 weeks. 2 Understanding and maximizing primary prevention strategies for asymptomatic carotid stenosis is therefore critical. Over the past decade, there has been a shift in thinking about management of patients with asymptomatic carotid artery disease, including reassessment of carotid endarterectomy (CEA) vs carotid artery stenting (CAS) vs medical management alone. Surgical trials in the 1990s demonstrated benefit in patients with more than 50% stenosis for patients with symptoms and more than 60% for patients who are asymptomatic; however, improving outcomes with statin use and more aggressive blood pressure control has since equalized the playing field and generated new questions about ideal treatment strategies. 3,4 In addition, cognitive function has emerged as an important outcome in carotid artery disease. Prevalence and Risk Factors Asymptomatic carotid stenosis of more than 50% has an age-dependent prevalence in men of 0.5% to 5.7% and in women of 0.3% to 4.4%. Among those with severe ( 70%) stenosis, rates are 0.1% to 1.7% in men and 0% to 0.9% in women. 5,6 Stroke rates among those with high-grade carotid stenosis were calculated to be 2% to 4% per year in 2002, 7 but dropped to 0.5% per year in 2013, largely owing to better medical management. 8 In a recent multicohort analysis that included 23,706 participants, age, male sex, history of vascular disease, systolic and diastolic blood pressure, total cholesterol/high-density lipoprotein (HDL) ratio, diabetes mellitus, and current smoking were independent predictors of moderate and severe stenosis. 7 Diagnosis Duplex Doppler (DD) ultrasound is the most common diagnostic modality for carotid stenosis worldwide and combines brightness/grayscale imaging of the vascular structures (B-mode) and quantitative representation of intraluminal flow velocities and waveforms (pulse-wave analysis). In an accredited laboratory with experienced technicians, DD ultrasound is accurate, safe, reliable, and inexpensive. Pulse-wave calculations of intraluminal flow velocities provide a highly replicable means of monitoring the degree of stenosis (Table). Additional information can be derived from the B-mode images of plaque morphology including intraplaque hemorrhage and plaque ulceration and mobile thrombi (Figure). Sensitivity and specificity of DD ultrasound screening is approximately 94% and 92%, respectively, for detecting stenosis of 60% to 99%. 9 Magnetic resonance angiography (MRA) and CT angiography (CTA) are alternatives to ultrasound and, in many settings, may be preferable if a Doppler lab is not available. The accuracy of MRA and CTA are similar to DD ultrasound and can provide additional information about plaque morphology and vascular pathology. Risk Stratification Several factors that mediate stroke risk in carotid artery stenosis have been used to stratify risk and guide management. 10 Higher degrees of stenosis are associated with higher risk of TABLE. DUPLEX DOPPLER ULTRASOUND MEASURES OF STENOSIS PSV, cm/sec EDV, cm/sec Moderate stenosis (49%-59%) Severe stenosis ( 70%) > 230 AND > 100 OR PSV:EDV ratio > 4.0 Abbreviations: EDV, end diastolic velocity; PSV, peak systolic flow velocity. 50 PRACTICAL NEUROLOGY JANUARY 2019
2 of acute stroke, regardless of the degree of stenosis. 20 This finding was replicated as part of a larger, event-driven clinical trial investigating atherosclerotic risk in patients with metabolic syndrome. 21 Among 232 subjects with asymptomatic carotid stenosis, high lipid content volume in the plaque (hazard ratio [HR] = 1.57, P =.002), and a thin or ruptured fibrous cap (HR = 4.32, P =.003) were associated with the combined endpoint of fatal and nonfatal myocardial infarction, ischemic stroke, acute coronary syndrome, and symptom-driven revascularization. Although 8.4% of subjects reached some endpoint over 3 years of observation, the incidence of stroke was 0.9%. Figure. Duplex Doppler image showing accelerated flow over an irregular, mixed density plaque in the internal carotid artery. stroke. 11,12 At the highest levels of stenosis (80%-99%) strokes are more likely to have hemodynamic etiology, as flow restriction increases ischemic injury risk in the distal field of the internal carotid artery (ICA). 13 In both hemodynamically significant lesions and in lower degrees of stenosis, morphologic characteristics of the plaque may determine risk. Strategies to stratify risk use direct imaging and physiologic measurements. Progression of Stenosis Progression of stenosis is associated with increasing stroke risk. A study showed the 8-year cumulative ipsilateral ischemic stroke rate was 0% in patients with regression of stenosis, 9% if stenosis was unchanged, and 16% if there was stenosis progression. 14 This risk may not hold for the very highest degree of stenosis, however. A recent large cohort analysis reported that the incidence of stroke among patients moving from asymptomatic carotid artery stenosis to complete occlusion was 0.3%. 15 Plaque Morphology Certain morphologic features of the carotid plaque are associated with increased stroke risk. The so-called vulnerable plaque includes a lipid-rich necrotic core, a thin fibrous cap, intraplaque hemorrhage, and plaque ulceration. 16 A lipid core is discernable by B-mode ultrasound as hypoechoic or hypoechoic with small hyperechoic areas. 17 Ulcerations and plaque hemorrhage can also be seen on Doppler ultrasound. With MRI carotid-wall imaging, presence of intraplaque hemorrhage, fibrous cap thinning or rupture and lipid-rich necrotic core are all predictive of future ipsilateral stroke or transient ischemic attack (TIA), and have been associated with ipsilateral cryptogenic stroke. 18,19 In a study of 114 patients with a spectrum of carotid stenoses who underwent multicontrast sequences for carotid wall imaging, a lipid rich necrotic core and carotid wall volume were associated with greater volume Microemboli Detection Another way of stratifying risk in patients with asymptomatic carotid stenosis is to use transcranial ultrasound (TCD) to detect microemboli released from high-grade carotid stenosis. A TCD headframe holds a 2-Hz ultrasound probe in place during monitoring. Detection of 2 or more microemboli over 1 hour is considered positive. 22 In a large prospective cohort study of 467 patients with asymptomatic carotid stenosis, the 2-year ipsilateral stroke risk was 3.62% in patients with embolic signals and 0.70% in those without (HR = 6.37; CI: ; P =.009). 23 In contrast, a similar earlier study showed a 1-year stroke risk of 15.6% in patients with embolic signals compared with a risk of only 1% among patients who were embolusnegative (P <.001). 24 The higher risk of stroke at the earlier time point occurred before adoption of more aggressive blood pressure control and use of statins. Cerebral Hemodynamics For higher-grade stenosis ( 70%), hemodynamic measurements can stratify risk. Here again, DD ultrasound offers a reliable and inexpensive approach. The most commonly used technique, cerebral vasomotor reactivity (CVR) with TCD, involves continuous monitoring of the middle cerebral artery (MCA) bilaterally or on the side of the carotid stenosis during a vasodilatory challenge. Patients hold their breath for 30 seconds to increase the PCO 2 in the bloodstream. Alternatively, 5% CO 2 can be administered via face mask. Because CO 2 is a potent vasodilator, the flow velocity will rise in the proximal MCA in response to vasodilation in the more distal arterioles. If the arterioles are already maximally vasodilated because of a chronic stenosis, response to CO 2 will be low or absent. Thus, this technique can be said to measure cerebrovascular reserve. Breath holding index (BHI) is calculated as: (MFV(bh) MFV)(base) / MFV(base) time (seconds) where MFV (bh) is mean flow velocity (MFV) during breath holding and MFV(base) is MFV at baseline. A BHI of less than 0.69 is abnormal. 25 A capnometer is required when using the CO 2 inhalation technique. For this method, the CVR calculation is the same as above, but the change in MFV is divided by JANUARY 2019 PRACTICAL NEUROLOGY 51
3 the rise in PCO 2, calculated as percent rise in MFV per mm Hg rise in PCO 2. Abnormal CVR is less than 2.0%. 26 The percentage cerebral blood flow velocity increase (pci) during any hypercapnic challenge should be 20% or more. 27 Measures of CVR are predictive of cerebrovascular ischemia. Among 94 patients with greater than 70% asymptomatic stenosis, those with impaired BHI had an annual ipsilateral stroke rate of 13.9% vs 4.1% among those with normal BHI. 25 Using the CO 2 inhalation technique, among 46 patients with 80% or more ICA stenosis or complete occlusion who were followed for 6 months, impaired CVR was associated with stroke or TIA (Fisher s exact test, P=.03). 26 In a meta-analysis from 9 studies comprising individual data from 754 patients with 70% or more carotid stenosis, CVR was independently associated with an increased risk of ipsilateral ischemic stroke among asymptomatic patients (HR = 2.90, [95% CI: ]; P =.047). 28 Management Medical Management The mainstay in treating patients with carotid artery disease for any degree of stenosis is aggressive medical treatment. Managing atherosclerotic risk factors is familiar to the general practitioner and the neurologist. Better control of blood pressure 29,30 and cholesterol, 31,32 attention to diet, and adopting a nonsedentary lifestyle have resulted in improved outcomes for patients with stroke and for asymptomatic carotid stenosis in particular. For asymptomatic patients with stenosis greater than 60%, surgical revascularization had historically been proven advantageous. A meta-analyses comparing treatment arms of carotid disease intervention trials over 15 years demonstrated that medical treatment of carotid artery disease has improved to the point of matching surgical outcomes among patients who are asymptomatic, with an annual stroke rate of 1.13% in 2010 compared with between 2% and 3% among patients who were recruited to randomized clinical trials before This finding has resulted in clinical practice moving toward medical management for asymptomatic ICA stenosis. With improved outcomes under new medical guidelines, surgical revascularization is being retested for efficacy. 52 PRACTICAL NEUROLOGY JANUARY 2019 Surgical Management Patients with symptomatic carotid artery stenosis benefit from early intervention with mechanical endarterectomy or stenting because of the high risk of early recurrence; the approach to these patients is unlikely to change substantially. Those with asymptomatic carotid stenosis, however, carry a lower overall stroke risk, and may no longer gain better outcomes with surgical vs medical treatment. The seminal asymptomatic carotid stenosis surgery trials were completed in the 1980s. The ACAS a in the United States, and the ACST b in Europe established the benefit of surgery over medical management. In ACAS, patients with 60% to 99% stenosis were enrolled and randomly assigned to receive CEA or medical therapy. Those with CEA had a 5-year ipsilateral stroke rate of 5.1% vs 11.0% for patients receiving medical therapy alone. 34 In ACST, similar results were seen in 3,120 patients randomly assigned to CEA vs deferred surgery until symptoms occurred. At 5 years, 6.9% of those who had CEA, experienced a stroke, compared with a stroke rate of 10.9% among those who did not have CEA. At 10 years, strokes had occurred in 17.9% of subjects in the medical-only group vs 13.4% in the group that had CEA. 35 Because these trials were completed before modern medical management and before the emergence of CAS, there was a need for additional trials. There was also a paucity of information about patients over age 80 years, and about women and minorities with carotid disease. The CREST c trial compared CEA with CAS in 2,522 patients with 70% or more carotid stenosis who were symptomatic or asymptomatic. There was no significant difference in the composite endpoint of any stroke, myocardial infarction, death during the periprocedural period or ipsilateral stroke in the 4-year follow up period (HR=1.18 [95% CI: ], P =.38]). Minor ipsilateral stroke was higher in patients who had CAS and myocardial infarction was higher in those who had CEA. Prespecified analysis did not show modification of the treatment effect by symptomatic status. In post hoc analysis, younger patients had slightly better outcomes with CAS, and older patients did slightly better with CEA. Although CREST showed equivalence between stenting and surgery, it did not address whether either intervention would do better compared with aggressive medical therapy alone. To address this question, the CREST-2 d trial was initiated 36 and combines 2 multicenter randomized trials, which randomly assign patients to receive CEA plus intensive medical management (IMM) vs IMM alone or to receive CAS plus IMM vs IMM alone. The primary risk factor targets for IMM are systolic blood pressure lower than 130 mm Hg and low-density lipoprotein (LDL) cholesterol less than 70 mg per dl. The primary outcome is the composite of stroke and death within 44 days of randomization, and stroke ipsilateral to the target vessel thereafter, up to 4 years. Change in cognition and differences in major and minor stroke are secondary outcomes. It is anticipated that this trial will answer the question of whether revascularization can still improve outcomes for asymptomatic carotid stenosis patients in the current environment of improved medical management for atherosclerosis. Cognition In face of our aging population, cognitive status has emerged as an important outcome measure in stroke studies. 37 Carotid artery stenosis is known to impact cognition through a number of mechanisms. General cerebrovascular risk factors such as hypertension, diabetes, and metabolic a Asymptomatic carotid atherosclerosis study. b Asymptomatic carotid surgery trial. c. Carotid revascularization endarterectomy versus stenting trial (NCT ). d. Carotid revascularization and medical management for asymptomatic carotid stenosis (NCT ).
4 syndrome are associated with vascular cognitive impairment (See Vascular Cognitive Impairment in this issue). Maximizing control of these factors can help prevent recurrent stroke that is associated with cognitive decline. 38 Plaque vulnerability and hemodynamic status have specific effects on cognitive function. Plaque Vulnerability Microemboli correlate with cognitive decline in patients with dementia, both among those with Alzheimer s disease (AD) and with vascular dementia (VaD). 39 Microemboli are known to occur with high-grade carotid stenosis, and are associated with silent infarction. In one population-based prospective cohort study, decline in cognitive function was associated with the appearance of new silent infarcts on follow up MRI, independent of the presence of silent infarcts at baseline. 40 In patients with asymptomatic carotid stenosis, a recent study showed that among 27 patients with more than 60% stenosis, those with a strain pattern on ultrasound a measure of plaque instability had high rates of microemboli. The strain measure correlated with cognitive dysfunction, particularly with executive function measures. 41 Hemodynamic Impairment Hemodynamic failure in high-grade carotid artery stenosis is associated with cognitive impairment. In a study of 210 patients with unilateral asymptomatic severe carotid stenosis, there was increased probability of developing cognitive deterioration compared with 109 subjects without carotid stenosis (odds ratio [OR] = 14.66, 95% CI ; P<.001). 42 Among 83 of these patients with unilateral highgrade carotid stenosis, impaired CVR was associated with cognitive impairment. This finding was demonstrated with cognitive tests specific to the ipsilateral hemisphere, further supporting the relationship between hypoperfusion and cognitive dysfunction. 43 Cognitive impairment associated with high-grade carotid stenosis may also be reversible with revascularization. A recent case series showed that among 137 patients with 70% to 99% carotid artery stenosis with TIA only in the prior 6 months, both CVR and cognitive performance improved 3 months after CEA. 44 A meta-analysis reviewed 16 studies for the impact of carotid stenting on cognition and found overall improvements in the modified Mini-Mental State Examination (MMSE) and tests of attention/psychomotor speed and memory. 45 Reversibility of cognitive decline would represent an important clinical outcome because vascular cognitive impairment, along with other causes of dementia, are generally not reversible. In order to test the reversibility hypothesis more rigorously, an ancillary study to CREST-2, the CREST-H e has begun and will test the hypothesis that the hemodynamically impaired subset of CREST-2 patients would benefit cognitively from revascularization. 46 A baseline perfusion MRI or CT, performed at baseline, will categorize patients into hemodynamically impaired or hemodynamically normal status. The primary outcome is cognitive status at 1 year, comparing those who get revascularized with those who receive IMM alone. What Do We Tell Our Patients? Management of asymptomatic carotid stenosis has evolved over the past 10 years. The seminal surgical studies that suggested revascularization would reduce stroke rate more than modern medical management may no longer be true. Aggressive medical management that includes controlling blood pressure to a target of 130/80 mm Hg, treating atherosclerosis with high potency, high-dose statins, and managing lifestyle choices of diet and exercise has become standard of care. Many vascular neurologists are eschewing CEA and CAS for patients with asymptomatic carotid stenosis and focusing on medical management alone. For clinical decision making for who should be sent for revascularization, testing for plaque instability, microemboli, and hemodynamic status may help determine which asymptomatic patients are at highest risk for stroke. With the CREST-2 trial, we now have a chance to rigorously retest our assumptions about surgical and interventional revascularization. Finally, cognitive function has emerged as an important outcome consideration. If cognitive impairment exists among a subset of our patients with asymptomatic carotid stenosis, we may need to re-assign them to symptomatic status, and consider the possibility that the cognitive impairment may be reversible with revascularization. n 1. Flaherty ML, Kissela B, Sucharew H, et al. The practice of carotid revascularization in a large metropolitan population. J Stroke Cerebrovasc Dis. 2013;22: Fairhead JF, Mehta Z, Rothwell PM. Population-based study of delays in carotid imaging and surgery and the risk of recurrent stroke. Neurology. 2005;65: Abbott AL, Nicolaides AN. Improving outcomes in patients with carotid stenosis: call for better research opportunities and standards. Stroke. 2015;46: Paraskevas KI, Veith FJ, Spence JD. How to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting. Stroke Vasc Neurol. 2018;3: de Weerd M, Greving JP, Hedblad B, et al. Prevalence of asymptomatic carotid artery stenosis in the general population: an individual participant data meta-analysis. Stroke. 2010;41: Longstreth WT Jr, Shemanski L, Lefkowitz D, et al. Asymptomatic internal carotid artery stenosis defined by ultrasound and the risk of subsequent stroke in the elderly. The Cardiovascular Health Study. Stroke. 1998;29: de Weerd M, Greving JP, Hedblad B, et al. Prediction of asymptomatic carotid artery stenosis in the general population: Identification of high-risk groups. Stroke. 2014;45: den Hartog AG, Achterberg S, Moll FL, et al. Asymptomatic carotid artery stenosis and the risk of ischemic stroke according to subtype in patients with clinical manifest arterial disease. Stroke. 2013;44: Wolff T, Guirguis-Blake J, Miller T, Gillespie M, Harris R. Screening For Asymptomatic Carotid Artery Stenosis [Internet]. In: Quality AfHRa, ed. U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews Gupta A, Marshall RS. Moving beyond luminal stenosis: imaging strategies for stroke prevention in asymptomatic carotid stenosis. Cerebrovasc Dis. 2015;39: Halliday A, Mansfield A, Marro J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004;363: Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 1991;325: Li Y, Li M, Zhang X, et al. Clinical features and the degree of cerebrovascular stenosis in different types and subtypes of cerebral watershed infarction. BMC Neurol. 2017;17: Kakkos SK, Nicolaides AN, Charalambous I, et al. Predictors and clinical significance of progression or regression of asymptomatic carotid stenosis. J Vasc Surg. 2014;59(4): e Yang C, Bogiatzi C, Spence JD. Risk of stroke at the time of carotid occlusion. JAMA Neurol. 2015;72: Redgrave JN, Lovett JK, Gallagher PJ, Rothwell PM. Histological assessment of 526 symptomatic carotid plaques in relation to the nature and timing of ischemic symptoms: The Oxford plaque study. Circulation. 2006;113: Gray-Weale AC, Graham JC, Burnett JR, Byrne K, Lusby RJ. Carotid artery atheroma: comparison of preoperative B-mode ultrasound appearance with carotid endarterectomy specimen pathology. J Cardiovasc Surg (Torino). 1988;29: (Continued on page 68) e. Carotid revascularization endarterectomy and stent trial hemodynamics (NCT ). JANUARY 2019 PRACTICAL NEUROLOGY 53
5 (Continued from page 53) 18. Gupta A, Gialdini G, Lerario MP, et al. Magnetic resonance angiography detection of abnormal carotid artery plaque in patients with cryptogenic stroke. J Am Heart Assoc. 2015;4(6):e Gupta A, Baradaran H, Schweitzer AD, et al. Carotid plaque MRI and stroke risk: a systematic review and meta-analysis. Stroke. 2013;44: Zhao H, Zhao X, Liu X, et al. Association of carotid atherosclerotic plaque features with acute ischemic stroke: a magnetic resonance imaging study. Eur J Radiol. 2013;82:e465-e Sun J, Zhao XQ, Balu N, et al. Carotid plaque lipid content and fibrous cap status predict systemic CV outcomes: the MRI substudy in AIM-HIGH. JACC Cardiovasc Imaging. 2017;10: Spence JD. Transcranial Doppler monitoring for microemboli: a marker of a high-risk carotid plaque. Semin Vasc Surg. 2017;30: Markus HS, King A, Shipley M, et al. Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observational study. Lancet Neurol. 2010;9: Spence JD, Tamayo A, Lownie SP, Ng WP, Ferguson GG. Absence of microemboli on transcranial Doppler identifies lowrisk patients with asymptomatic carotid stenosis. Stroke. 2005;36: Silvestrini M, Vernieri F, Pasqualetti P, et al. Impaired cerebral vasoreactivity and risk of stroke in patients with asymptomatic carotid artery stenosis. JAMA. 2000;283: Marshall RS, Rundek T, Sproule DM, Fitzsimmons BF, Schwartz S, Lazar RM. Monitoring of cerebral vasodilatory capacity with transcranial Doppler carbon dioxide inhalation in patients with severe carotid artery disease. Stroke. 2003;34: Markus H, Cullinane M. Severely impaired cerebrovascular reactivity predicts stroke and TIA risk in patients with carotid artery stenosis and occlusion. Brain. 2001;124: Reinhard M, Schwarzer G, Briel M, et al. Cerebrovascular reactivity predicts stroke in high-grade carotid artery disease. Neurology. 2014;83: Wright JT Jr, Whelton PK, Reboussin DM. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2016;374(23): Group AS, Cushman WC, Evans GW, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362: Sillesen H, Amarenco P, Hennerici MG, et al. Atorvastatin reduces the risk of cardiovascular events in patients with carotid atherosclerosis: a secondary analysis of the stroke prevention by aggressive reduction in cholesterol levels (SPARCL) trial. Stroke. 2008;39: Ridker PM, Genest J, Boekholdt SM, et al. HDL cholesterol and residual risk of first cardiovascular events after treatment with potent statin therapy: an analysis from the JUPITER trial. Lancet. 2010;376: Raman G, Moorthy D, Hadar N, et al. Management strategies for asymptomatic carotid stenosis: a systematic review and meta-analysis. Ann Intern Med. 2013;158(9): Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis study. JAMA. 1995;273: Brott TG, Hobson RW 2nd, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363: Howard VJ, Meschia JF, Lal BK, et al. Carotid revascularization and medical management for asymptomatic carotid stenosis: protocol of the CREST-2 clinical trials. Int J Stroke. 2017;12: Rich MW, Chyun DA, Skolnick AH, et al. Knowledge gaps in cardiovascular care of the older adult population: a scientific statement from the American Heart Association, American College of Cardiology, and American Geriatrics Society. J Am Coll Cardiol. 2016;67: Liu CL, Lin MY, Hwang SJ, Liu CK, Lee HL, Wu MT. Factors associated with type 2 diabetes in patients with vascular dementia: a population-based cross-sectional study. BMC Endocrine Disorders. 2018;18: Purandare N, Voshaar RC, Morris J, et al. Asymptomatic spontaneous cerebral emboli predict cognitive and functional decline in dementia. Biol Psychiatry. 2007;62: Vermeer SE, Prins ND, den Heijer T,et al. Silent brain infarcts and the risk of dementia and cognitive decline. N Engl J Med. 2003;348: Dempsey RJ, Varghese T, Jackson DC, et al. Carotid atherosclerotic plaque instability and cognition determined by ultrasound-measured plaque strain in asymptomatic patients with significant stenosis. J Neurosurg. 2018;128: Balestrini S, Perozzi C, Altamura C, et al. Severe carotid stenosis and impaired cerebral hemodynamics can influence cognitive deterioration. Neurology. 2013;80: Silvestrini M, Paolino I, Vernieri F, et al. Cerebral hemodynamics and cognitive performance in patients with asymptomatic carotid stenosis. Neurology. 2009;72: Lattanzi S, Carbonari L, Pagliariccio G, et al. Neurocognitive functioning and cerebrovascular reactivity after carotid endarterectomy. Neurology. 2018;90(4):e307-e Antonopoulos CN, Kakisis JD, Sfyroeras GS, et al. The impact of carotid artery stenting on cognitive function in patients with extracranial carotid artery stenosis. Ann Vasc Surg. 2015;29(3): Marshall RS, Lazar RM, Liebeskind DS, et al. Carotid revascularization and medical management for asymptomatic carotid stenosis - Hemodynamics (CREST-H): study design and rationale. Int J Stroke. 2018:13(9): Randolph S. Marshall, MD, MS Elisabeth K. Harris Professor of Neurology Chief, Division of Stroke and Cerebrovascular Diseases Department of Neurology Columbia University Irving Medical Center New York, NY Disclosure The author has no financial or other relationships relevant to this content to disclose. 68 PRACTICAL NEUROLOGY JANUARY 2019
Disclosures. State of the Art Management of Carotid Stenosis. NIH funding for clinical trials Consultant for Scientia Vascular and Medtronic
State of the Art Management of Carotid Stenosis Mark R. Harrigan, MD UAB Stroke Center Professor of Neurosurgery, Neurology, and Radiology University of Alabama, Birmingham Disclosures NIH funding for
More informationAsymptomatic Carotid Stenosis To Do or Not To Do
Asymptomatic Carotid Stenosis To Do or Not To Do October 22, 2016 Neurosciences: Updates and Controversies Andrew C. MacDougall, MD Advocate Medical Group Advocate Lutheran General Hospital Principle
More information03/30/2016 DISCLOSURES TO OPERATE OR NOT THAT IS THE QUESTION CAROTID INTERVENTION IS INDICATED FOR ASYMPTOMATIC CAROTID OCCLUSIVE DISEASE
CAROTID INTERVENTION IS INDICATED FOR ASYMPTOMATIC CAROTID OCCLUSIVE DISEASE Elizabeth L. Detschelt, M.D. Allegheny Health Network Vascular and Endovascular Symposium April 2, 2016 DISCLOSURES I have no
More informationEmboli detection to evaluate risk of stroke
Emboli detection to evaluate risk of stroke Background: Improved methods are required to identify patients with asymptomatic carotid stenosis at high risk for stroke. Whether surgery is beneficial for
More informationStroke prevention in asymptomatic carotid stenosis. ΛΙΛΛΗΣ ΛΕΩΝΙΔΑΣ Καρδιολόγος Επιστημονικός Συνεργάτης Α Καρδιολογικής Κλινικής ΑΠΘ ΠΓΝΘ ΑΧΕΠΑ
Stroke prevention in asymptomatic carotid stenosis ΛΙΛΛΗΣ ΛΕΩΝΙΔΑΣ Καρδιολόγος Επιστημονικός Συνεργάτης Α Καρδιολογικής Κλινικής ΑΠΘ ΠΓΝΘ ΑΧΕΠΑ Σεμινάρια Ομάδων Εργασίας Ελληνικής Καρδιολογικής Εταιρείας
More informationSpontaneous embolisation on TCD and carotid plaque features
Spontaneous embolisation on TCD and carotid plaque features J. David Spence Stroke Prevention & Atherosclerosis Research Centre Robarts Research Institute London, Canada dspence@robarts.ca www.imaging.robarts.ca/sparc
More informationTreatment Considerations for Carotid Artery Stenosis. Danielle Zielinski, RN, MSN, ACNP Rush University Neurosurgery
Treatment Considerations for Carotid Artery Stenosis Danielle Zielinski, RN, MSN, ACNP Rush University Neurosurgery 4.29.2016 There is no actual or potential conflict of interest in regards to this presentation
More informationSlide 1. Slide 2 Conflict of Interest Disclosure. Slide 3 Stroke Facts. The Treatment of Intracranial Stenosis. Disclosure
Slide 1 The Treatment of Intracranial Stenosis Helmi Lutsep, MD Vice Chair and Dixon Term Professor, Department of Neurology, Oregon Health & Science University Chief of Neurology, VA Portland Health Care
More informationContemporary Carotid Imaging and Approach to Treatment: Course Notes Thursday, June 22, 2017 David M. Pelz, MD, FRCPC
CNSF Meeting, Victoria, BC. June 2017 Contemporary Carotid Imaging and Approach to Treatment: Course Notes Thursday, June 22, 2017 David M. Pelz, MD, FRCPC A. Objectives 1. To understand the current imaging
More informationCurrent Status and Perspectives of ACST-2, CREST-2, ECST-2 and ACTRIS. Richard Bulbulia Co-Principal Investigator ACST-2 University of Oxford
Current Status and Perspectives of ACST-2, CREST-2, ECST-2 and ACTRIS Richard Bulbulia Co-Principal Investigator ACST-2 University of Oxford Two BIG questions in carotid research Question #1 Should we
More informationCarotid Artery Stenosis
Evidence-Based Approach to Carotid Artery Stenosis Seong-Wook Park, MD Division of Cardiology, Asan Medical Center University of Ulsan College of Medicine, Seoul, Korea Carotid Artery Stenosis Carotid
More informationMORTALITY AND MORBIDITY RISK FROM CAROTID ARTERY ATHEROSCLEROSIS. 73 year old NS right-handed male applicant for $1 Million life insurance
MORTALITY AND MORBIDITY RISK FROM CAROTID ARTERY ATHEROSCLEROSIS October 17, 2012 AAIM Triennial Conference, San Diego Robert Lund, MD What Is The Risk? 73 year old NS right-handed male applicant for $1
More informationMORTALITY AND MORBIDITY RISK FROM CAROTID ARTERY ATHEROSCLEROSIS. 73 year old NS right-handed male applicant for $1 Million Life Insurance
MORTALITY AND MORBIDITY RISK FROM CAROTID ARTERY ATHEROSCLEROSIS October 17, 2012 AAIM Triennial Conference, San Diego Robert Lund, MD What Is The Risk? 73 year old NS right-handed male applicant for $1
More informationThe argument against revascularization for asymptomatic carotid stenosis
The argument against revascularization for asymptomatic carotid stenosis Seemant Chaturvedi, MD, FAHA, FAAN Professor of Clinical Neurology Vice-Chair for VA Programs Univ. of Miami Miller School of Medicine
More informationPre-and Post Procedure Non-Invasive Evaluation of the Patient with Carotid Disease
Pre-and Post Procedure Non-Invasive Evaluation of the Patient with Carotid Disease Michael R. Jaff, D.O., F.A.C.P., F.A.C.C. Assistant Professor of Medicine Harvard Medical School Director, Vascular Medicine
More informationPrise en charge du polyvasculaire
Prise en charge du polyvasculaire Dépistage et prise en charge des sténoses carotidiennes Serge Kownator Centre cardiologique et Vasculaire - Thionville Disclosure Statement of Financial Interest I currently
More informationCAROTID DEBATE High-Grade Asymptomatic Disease Should Be Repaired Selectively; Medical Management is NOT Enough
Todd W GenslerMD April 28, 2018 CAROTID DEBATE High-Grade Asymptomatic Disease Should Be Repaired Selectively; Medical Management is NOT Enough DISCLOSURES I have no financial disclosures Presenter name
More informationThe recent joint guidelines[1] of the European Society of Cardiology and European
Supplementary material Musiałek P, Grunwald IQ. How asymptomatic is asymptomatic carotid stenosis? Resolving confusion(s) and confusions yet to be resolved. Pol Arch Intern Med. 2017. doi: Please note
More informationContemporary Management of Carotid Disease What We Know So Far
Contemporary Management of Carotid Disease What We Know So Far Ammar Safar, MD, FSCAI, FACC, FACP, RPVI Interventional Cardiology & Endovascular Medicine Disclosers NONE Epidemiology 80 % of stroke are
More informationCarotid Artery Stenting (CAS) Pathophysiology. Technical Considerations. Plaque characteristics: relevant concepts. CAS and CEA
Carotid Artery Stenting (CAS) Carotid Artery Stenting for Stroke Risk Reduction Matthew A. Corriere MD, MS, RPVI Assistant Professor of Surgery Department of Vascular and Endovascular Surgery Rationale:
More informationCEA or CAS for asymptomatic carotid stenosis which patients benefit most?
CEA or CAS for asymptomatic carotid stenosis which patients benefit most? Alison Halliday Professor of Vascular Surgery University of Oxford Keynote Lecture, MAC, December 6 th 2018 Clinical/imaging characteristics
More informationHow to Choose Between Carotid Stenting and Carotid Endarterectomy for Stroke Prevention
How to Choose Between Carotid Stenting and Carotid Endarterectomy for Stroke Prevention Christopher J. White MD, MSCAI Chief of Medical Services, Professor and Chairman of Medicine Ochsner Medical Center
More informationESC Heart & Brain Workshop
ESC Heart & Brain Workshop The role of vascular surgeon in stroke prevention Barbara Rantner, MD, PhD, Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria Supported by Bayer,
More informationCarotid Artery Disease How the Data Will Influence Management The Symptomatic vs. the Asymptomatic Patient
Carotid Artery Disease How the 2014-2015 Data Will Influence Management The Symptomatic vs. the Asymptomatic Patient Christopher J. White, MD, MSCAI, FACC, FAHA, FESC Professor and Chair of Medicine Ochsner
More informationCarotid Artery Disease and What s Pertinent JOSEPH A PAULISIN DO
Carotid Artery Disease and What s Pertinent JOSEPH A PAULISIN DO Goal of treatment of carotid disease Identify those at risk of developing symptoms Prevent patients at risk from developing symptoms Prevent
More informationcollaterals offset ischemia
Imaging of Intracranial Stenosis objectives & next steps collaterals offset ischemia systematic evaluation of collaterals hemodynamic impact, not % stenosis develop fractional flow measures collateral
More informationCarotid Endarterectomy for Symptomatic Complete Occlusion of the Internal Carotid Artery
2011 65 4 239 245 Carotid Endarterectomy for Symptomatic Complete Occlusion of the Internal Carotid Artery a* a b a a a b 240 65 4 2011 241 9 1 60 10 2 62 17 3 67 2 4 64 7 5 69 5 6 71 1 7 55 13 8 73 1
More informationVascular disease. Structural evaluation of vascular disease. Goo-Yeong Cho, MD, PhD Seoul National University Bundang Hospital
Vascular disease. Structural evaluation of vascular disease Goo-Yeong Cho, MD, PhD Seoul National University Bundang Hospital resistance vessels : arteries
More informationCarotid Artery Stenting
Carotid Artery Stenting Woong Chol Kang M.D. Gil Medical Center, Gachon University of Medicine and Science, Incheon, Korea Carotid Stenosis and Stroke ~25% of stroke is due to carotid disease, the reminder
More informationProtokollanhang zur SPACE-2-Studie Neurology Quality Standards
Protokollanhang zur SPACE-2-Studie Neurology Quality Standards 1. General remarks In contrast to SPACE-1, the neurological center participating in the SPACE-2 trial will also be involved in the treatment
More informationClinical Decision Making: Hyperacute Management of Symptomatic Carotid Artery Disease
Clinical Decision Making: Hyperacute Management of Symptomatic Carotid Artery Disease Tarvinder Singh, MS, MD Neurohospitalist Swedish Neuroscience Institute 1 Objectives Definition Why the urgency? Evidence/Guidelines
More informationCarotid Artery Stenting Versus
Carotid Artery Stenting Versus Carotid Endarterectomy Seong-Wook Park, MD, PhD, FACC,, Seoul, Korea Stroke & Carotid artery stenosis Stroke & Carotid artery stenosis Cerebrovascular disease is one of the
More informationNon-invasive Imaging of Carotid Artery Atherosclerosis
Non-invasive Imaging of Carotid Artery Atherosclerosis 최연현 성균관의대삼성서울병원영상의학과 Noninvasive Techniques US with Doppler CT MRI Ultrasonography Techniques of Carotid US US Anatomy (ICA vs ECA) Gray scale and
More informationNew Trials in Progress: ACT 1. Jon Matsumura, MD Cannes, France June 28, 2008
New Trials in Progress: ACT 1 Jon Matsumura, MD Cannes, France June 28, 2008 Faculty Disclosure I disclose the following financial relationships: Consultant, CAS training director, and/or research grants
More informationThe Effectiveness of Medical Therapy for Severe Carotid Stenosis in Reducing Large-Vessel Embolic Stroke: Open Question or Question Answered?
TCT 2009 San Francisco, California September 22, 2009 The Effectiveness of Medical Therapy for Severe Carotid Stenosis in Reducing Large-Vessel Embolic Stroke: Open Question or Question Answered? Michael
More informationRecanalization of Chronic Carotid Artery Occlusion Objective Improvement Of Cerebral Perfusion
Recanalization of Chronic Carotid Artery Occlusion Objective Improvement Of Cerebral Perfusion Paul Hsien-Li Kao, MD Assistant Professor National Taiwan University Medical School and Hospital ICA stenting
More informationMorphological duplex ultrasound criteria how to assess and report echolucency, inhomogeneity and ulceration
Morphological duplex ultrasound criteria how to assess and report echolucency, inhomogeneity and ulceration Prof. Daniel Staub, Angiology, University Hospital Basel, Switzerland daniel.staub@usb.ch Disclosure
More informationBeyond Stenosis Severity: Top 5 Important Duplex Characteristics to Identify in a Patient with Carotid Disease
Beyond Stenosis Severity: Top 5 Important Duplex Characteristics to Identify in a Patient with Carotid Disease Jan M. Sloves RVT, RCS, FASE Technical Director New York Cardiovascular Associates Disclosures
More informationThe most important recommendations from the 2017 ESVS/ESC guideline on the management of carotid artery disease
The most important recommendations from the 2017 ESVS/ESC guideline on the management of carotid artery disease GJ de Borst Department of Vascular Surgery RECOMMENDATION GRADING CRITERIA What is new
More informationORIGINAL CONTRIBUTION. Long-term Risk of Stroke and Other Vascular Events in Patients With Asymptomatic Carotid Artery Stenosis
ORIGINAL CONTRIBUTION Long-term Risk of Stroke and Other Vascular Events in Patients With Asymptomatic Carotid Artery Stenosis Zurab G. Nadareishvili, MD, PhD; Peter M. Rothwell, MD, PhD; Vadim Beletsky,
More informationThresholds of impaired cerebral hemodynamics that predict short-term cognitive decline in asymptomatic carotid stenosis
Original Article Thresholds of impaired cerebral hemodynamics that predict short-term cognitive decline in asymptomatic carotid stenosis Journal of Cerebral Blood Flow & Metabolism 0(00) 1 9! Author(s)
More informationInternational Journal of Stroke
10-year risk of stroke in patients with previous cerebral infarction and the impact of carotid surgery in the Asymptomatic Carotid Surgery Trial (ACST-1) Journal: International Journal of Stroke Manuscript
More informationThe Great Swedish Debate. Håkan Pärsson Department Vascular Surgery Helsingborgs Lasarett, University Lund
The Great Swedish Debate Håkan Pärsson Department Vascular Surgery Helsingborgs Lasarett, University Lund My Disclosures Trying to bribe the moderators What do my patients expect? Balanced information
More informationCarotid Atherosclerosis in Ischemic Cerebrovascular Patients
Original Article Carotid Atherosclerosis in Ischemic Cerebrovascular Patients Ai Juan Zhang a, c, Ai Yuan Zhang b, Chi Zhong a Abstract Background: Cerebral emboli resulting from atherosclerosis at the
More informationLARGE ARTERY DISEASE pathophysiology of ischemic insults. ISCHEMIC STROKE & TIA main etiologies
תאריך בדיקה- 27.1.04 דופלקס עורקי צוואר - משמעות בגיל הקשיש דר' יונתן שטרייפלר מנהל היחידה הנוירולוגית מרכז רפואי רבין - בי"ח השרון ISCHEMIC STROKE & TIA main etiologies Large vessel (artery) disease -
More informationLecture Outline: 1/5/14
John P. Karis, MD Lecture Outline: Provide a clinical overview of stroke: Risk Prevention Diagnosis Intervention Illustrate how MRI is used in the diagnosis and management of stroke. Illustrate how competing
More informationUpdate : Carotid Stenting and Current Trial Data
Update : Carotid Stenting and Current Trial Data J. Michael Bacharach, MD, MPH, FACC, FSCAI Section Head, Vascular Medicine and Vascular Intervention North Central Heart Institute, Sioux Falls, South Dakota
More informationClinical experience amongst surgeons in the Asymptomatic Carotid Surgery Trial-1 (ACST-1)
Clinical experience amongst surgeons in the Asymptomatic Carotid Surgery Trial-1 (ACST-1) Short Title: Clinical experience in the Asymptomatic Carotid Surgery Trial-1 (ACST-1) Authors: Anne Huibers 1,2,
More informationAdvances in the treatment of posterior cerebral circulation symptomatic disease
Advances in the treatment of posterior cerebral circulation symptomatic disease Athanasios D. Giannoukas MD, MSc(Lond.), PhD(Lond.), FEBVS Professor of Vascular Surgery Faculty of Medicine, School of Health
More informationISCHEMIC STROKE & TIA main etiologies
דופלקס עורקי צוואר - משמעות בגיל הקשיש דר' יונתן שטרייפלר מנהל היחידה הנוירולוגית מרכז רפואי רבין - בי"ח השרון תאריך בדיקה- 27.1.04 ISCHEMIC STROKE & TIA main etiologies Large vessel (artery) disease -
More informationCo chce/čeká neurochirug od anesteziologa během karotické endarterektomie?
XXV. kongres České společnosti anesteziologie, resuscitace a intenzivní medicíny, Praha 3.-5.10. 2018 Co chce/čeká neurochirug od anesteziologa během karotické endarterektomie? Hejčl A., Orlický M., Sameš
More informationCarotid Endarterectomy vs. Carotid artery Stenting (Surgeon Perspective)
Carotid Endarterectomy vs. Carotid artery Stenting (Surgeon Perspective) T-Woei Tan, MD, FACS, RPVI Assistant Professor of Surgery Vascular and Endovascular Surgery Louisiana State University Health -
More informationUpdated Society for Vascular Surgery guidelines for management of extracranial carotid disease: Executive summary
SOCIETY FOR VASCULAR SURGERY DOCUMENT Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease: Executive summary John J. Ricotta, MD, a Ali AbuRahma, MD, FACS, b
More informationThe Epidemiology of Stroke and Vascular Risk Factors in Cognitive Aging
The Epidemiology of Stroke and Vascular Risk Factors in Cognitive Aging REBECCA F. GOTTESMAN, MD PHD ASSOCIATE PROFESSOR OF NEUROLOGY AND EPIDEMIOLOGY JOHNS HOPKINS UNIVERSITY OCTOBER 20, 2014 Outline
More informationCHAPTER 5. Symptomatic and Asymptomatic Retinal Embolism Have Different Mechanisms
CHAPTER 5 Symptomatic and Asymptomatic Retinal Embolism Have Different Mechanisms Christine A.C. Wijman, Joao A. Gomes, Michael R. Winter, Behrooz Koleini, Ippolit C.A. Matjucha, Val E. Pochay, Viken L.
More informationVivek R. Deshmukh, MD Director, Cerebrovascular and Endovascular Neurosurgery Chairman, Department of Neurosurgery Providence Brain and Spine
Vivek R. Deshmukh, MD Director, Cerebrovascular and Endovascular Neurosurgery Chairman, Department of Neurosurgery Providence Brain and Spine Institute The Oregon Clinic Disclosure I declare that neither
More informationHow Duplex Ultrasound Screening Can Lead to Overuse of Carotid Interventions. No Disclosures. Prevalence >70% Asymptomatic ICA Stenosis*
How Duplex Ultrasound Screening Can Lead to Overuse of Carotid Interventions Gregory L. Moneta, M.D. Chief, Division of Vascular Surgery Department of Surgery Knight Cardiovascular Institute Oregon Health
More informationCarotid Ultrasound: Improving Ultrasound
Carotid Ultrasound: Improving Ultrasound Edward I. Bluth, M.D., F.A.C.R. Chairman Emeritus, Department of Radiology, Ochsner Clinic Foundation, New Orleans, Louisiana Professor, Ochsner Clinical School,
More informationThe JUPITER trial: What does it tell us? Alice Y.Y. Cheng, MD, FRCPC January 24, 2009
The JUPITER trial: What does it tell us? Alice Y.Y. Cheng, MD, FRCPC January 24, 2009 Learning Objectives 1. Understand the role of statin therapy in the primary and secondary prevention of stroke 2. Explain
More informationCarotid Artery Revascularization: Current Strategies. Shonda Banegas, D.O. Vascular Surgery Carondelet Heart and Vascular Institute September 6, 2014
Carotid Artery Revascularization: Current Strategies Shonda Banegas, D.O. Vascular Surgery Carondelet Heart and Vascular Institute September 6, 2014 Disclosures None 1 Stroke in 2014 Stroke kills almost
More informationFor the ICSS Investigators. 7 th Munich Vascular Conference Munich, 7 December 2017
Restenosis and its impact on recurrent stroke risks after CAS and CEA for symptomatic carotid stenosis results from the International Carotid Stenting Study Leo H Bonati, John Gregson, Joanna Dobson, Dominick
More informationCategorical Course: Update of Doppler US 8 : 00 8 : 20
159 Categorical Course: Update of Doppler US 8 : 00 8 : 20 160 161 Table 1.Comparison of Recommended Values from Data in the Published Literature* S t u d y Lesion PSV E D V VICA/VCCA S e v e r i t y (
More informationManagement of intracranial atherosclerotic stenosis (ICAS)/intracranial atherosclerosis
Management of intracranial atherosclerotic stenosis (ICAS)/intracranial atherosclerosis Tim Mikesell, D.O. Oct 22, 2016 Stroke facts Despite progress in decreasing stroke incidence and mortality, stroke
More informationSession : Why do stroke patients need a cardiologist? PREVALENCE OF CORONARY ATHEROSCLEROSIS IN PATIENTS WITH CEREBRAL INFARCTION
Session : Why do stroke patients need a cardiologist? PREVALENCE OF CORONARY ATHEROSCLEROSIS IN PATIENTS WITH CEREBRAL INFARCTION The Asymptomatic Myocardial Ischemia in Stroke and Atherosclerotic Disease
More informationPreoperative risk factors for carotid endarterectomy: Defining the patient at high risk
Preoperative risk factors for carotid endarterectomy: Defining the patient at high risk Amy B. Reed, MD, a Peter Gaccione, MA, b Michael Belkin, MD, b Magruder C. Donaldson, MD, b John A. Mannick, MD,
More informationEzetimibe and SimvastatiN in Hypercholesterolemia EnhANces AtherosClerosis REgression (ENHANCE)
Ezetimibe and SimvastatiN in Hypercholesterolemia EnhANces AtherosClerosis REgression (ENHANCE) Thomas Dayspring, MD, FACP Clinical Assistant Professor of Medicine University of Medicine and Dentistry
More informationFRANK J. VEITH MAC TH MUNICH VASCULAR CONF
UPDATE ON THE NORTH AMERICAN RCTs CREST 2 & ACST 1: WILL CAS SURVIVE AS AN ALTERNATIVE TO BMT OR CEA? FRANK J. VEITH 6 TH MUNICH VASCULAR CONF MAC - 2016 MUNICH DECEMBER 1, 2016 I HAVE NO FINANCIAL CONFLICTS
More informationThe Effect of Statin Therapy on Risk of Intracranial Hemorrhage
The Effect of Statin Therapy on Risk of Intracranial Hemorrhage JENNIFER HANIFY, PHARM.D. PGY2 CRITICAL CARE RESIDENT UF HEALTH JACKSONVILLE JANUARY 23 RD 2016 Objectives Review benefits of statin therapy
More informationPeripheral Arterial Occlusive Disease- The Challenge in patients with diabetes
Peripheral Arterial Occlusive Disease- The Challenge in patients with diabetes Ashok Handa Reader in Surgery and Consultant Surgeon Nuffield Department of Surgery University of Oxford Introduction Vascular
More informationInternal carotid artery near-total occlusions: Is it justified to operate on them?
Internal carotid artery near-total occlusions: Is it justified to operate on them? Christos D. Liapis Professor (Em) of Vascular Surgery Athens University Medical School Director Vascular & Endovascular
More informationESC Congress 2011 SIMULTANEOUS HYBRID REVASCULARIZATION OF CAROTID AND CORONARY DISEASE INITIAL RESULTS OF A NEW THERAPEUTIC APPROACH
ESC Congress 2011 SIMULTANEOUS HYBRID REVASCULARIZATION OF CAROTID AND CORONARY DISEASE IN PATIENTS WITH ACUTE CORONARY SYNDROME: INITIAL RESULTS OF A NEW THERAPEUTIC APPROACH AUTHORS: Marta Ponte 1, RICARDO
More information4/7/ The stats on heart disease. + Deaths & Age-Adjusted Death Rates for
+ Update on Lipid Management Stacey Gardiner, MD Assistant Professor Division of Cardiovascular Medicine Medical College of Wisconsin + The stats on heart disease Over the past 10 years for which statistics
More informationEndarterectomy for Mild Cervical Carotid Artery Stenosis in Patients With Ischemic Stroke Events Refractory to Medical Treatment
Neurol Med Chir (Tokyo) 48, 211 215, 2008 Endarterectomy for Mild Cervical Carotid Artery Stenosis in Patients With Ischemic Stroke Events Refractory to Medical Treatment Two Case Reports Masakazu KOBAYASHI,
More informationCEA and cerebral protection Volodymyr labinskyy, MD
CEA and cerebral protection Volodymyr labinskyy, MD VA Hospital 7/26/2012 63 year old male presents for the vascular evaluation s/p TIA in January 2012 PMH: HTN, long term active smoker, Hep C PSH: None
More informationAlma Mater Studiorum Università di Bologna
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
More informationHow would you manage Ms. Gold
How would you manage Ms. Gold 32 yo Asian woman with dyslipidemia Current medications: Simvastatin 20mg QD Most recent lipid profile: TC = 246, TG = 100, LDL = 176, HDL = 50 What about Mr. Williams? 56
More informationRole of ABI in Detecting and Quantifying Peripheral Arterial Disease
Role of ABI in Detecting and Quantifying Peripheral Arterial Disease Difference in AAA size between US and Surgeon 2 1 0-1 -2-3 0 1 2 3 4 5 6 7 Mean AAA size between US and Surgeon Kathleen G. Raman MD,
More informationWhich CVS risk reduction strategy fits better to carotid US findings?
Which CVS risk reduction strategy fits better to carotid US findings? Dougalis A, Soulaidopoulos S, Cholongitas E, Chalevas P, Vettas Ch, Doumtsis P, Vaitsi K, Diavasti M, Mandala E, Garyfallos A 4th Department
More informationMR Imaging of Atherosclerotic Plaques
MR Imaging of Atherosclerotic Plaques Yeon Hyeon Choe, MD Department of Radiology, Samsung Medical Center, Sungkyunkwan University, Seoul MRI for Carotid Atheroma Excellent tissue contrast (fat, fibrous
More informationCarotid Artery Stent: Is it ready for prime time?
2010 CATH LAB SYMPOSIUM Carotid Artery Stent: Is it ready for prime time? Luis F. Tami, MD, FACC, FSCAI Interventional Cardiology and Vascular Medicine Memorial Regional Hospital August 2010 CAE and CAS
More informationThe CARENET all-comer trial using the CGuard micronet covered carotid embolic prevention stent
The CARENET all-comer trial using the CGuard micronet covered carotid embolic prevention stent 6 month data Piotr Musialek, MD DPhil FESC Jagiellonian University Dept. of Cardiac & Vascular Diseases John
More informationCVD risk assessment using risk scores in primary and secondary prevention
CVD risk assessment using risk scores in primary and secondary prevention Raul D. Santos MD, PhD Heart Institute-InCor University of Sao Paulo Brazil Disclosure Honoraria for consulting and speaker activities
More informationGuidelines for Ultrasound Surveillance
Guidelines for Ultrasound Surveillance Carotid & Lower Extremity by Ian Hamilton, Jr, MD, MBA, RPVI, FACS Corporate Medical Director BlueCross BlueShield of Tennessee guidelines for ultrasound surveillance
More informationAdvances in Prevention and Treatment of Stroke: What Every Primary Care Physician Needs to Know. Case 1 4/5/11. What treatment should you initiate?
Advances in Prevention and Treatment of Stroke: What Every Primary Care Physician Needs to Know S. Andrew Josephson, MD Director, Neurohospitalist Program Medical Director, Inpatient Neurology University
More informationAntiplatelet Therapy in Primary CVD Prevention and Stable Coronary Artery Disease. Καρακώστας Γεώργιος Διευθυντής Καρδιολογικής Κλινικής, Γ.Ν.
Antiplatelet Therapy in Primary CVD Prevention and Stable Coronary Artery Disease Καρακώστας Γεώργιος Διευθυντής Καρδιολογικής Κλινικής, Γ.Ν.Κιλκίς Primary CVD Prevention A co-ordinated set of actions,
More informationJoshua A. Beckman, MD. Brigham and Women s Hospital
Peripheral Vascular Disease: Overview, Peripheral Arterial Obstructive Disease, Carotid Artery Disease, and Renovascular Disease as a Surrogate for Coronary Artery Disease Joshua A. Beckman, MD Brigham
More informationA Base of Observations and a Base of Knowledge for «Carotid constriction» Disease Formed by the Ontology for Medical Diagnostics
A Base of Observations and a Base of Knowledge for «Carotid constriction» Disease Formed by the Ontology for Medical Diagnostics Mery Yu. Chernyakhovskaya, and Philip M. Moskalenko Abstract--The paper
More information5/2/2016. Outpatient Stroke Management Sheila Smith MD May 5, 2016
Outpatient Stroke Management Sheila Smith MD May 5, 2016 1 Management of Outpatient Stroke Objectives Review blood pressure management post stroke Review antithrombotic therapy Review statin therapy Discuss
More informationAndrew Cohen, MD and Neil S. Skolnik, MD INTRODUCTION
2 Hyperlipidemia Andrew Cohen, MD and Neil S. Skolnik, MD CONTENTS INTRODUCTION RISK CATEGORIES AND TARGET LDL-CHOLESTEROL TREATMENT OF LDL-CHOLESTEROL SPECIAL CONSIDERATIONS OLDER AND YOUNGER ADULTS ADDITIONAL
More informationSubclinical atherosclerosis in CVD: Risk stratification & management Raul Santos, MD
Subclinical atherosclerosis in CVD: Risk stratification & management Raul Santos, MD Sao Paulo Medical School Sao Paolo, Brazil Subclinical atherosclerosis in CVD risk: Stratification & management Prof.
More informationDisclosures. CREST Trial: Summary. Lecture Outline 4/16/2015. Cervical Atherosclerotic Disease
Disclosures Your Patient Has Carotid Bulb Stenosis and a Tandem Intracranial Stenosis: How Do SAMMPRIS and Other Evidence Inform Your Treatment? UCSF Vascular Symposium 2015 Steven W. Hetts, MD Associate
More informationThe TNT Trial Is It Time to Shift Our Goals in Clinical
The TNT Trial Is It Time to Shift Our Goals in Clinical Angioplasty Summit Luncheon Symposium Korea Assoc Prof David Colquhoun 29 April 2005 University of Queensland, Wesley Hospital, Brisbane, Australia
More informationPlaque Imaging: What It Can Tell Us. Kenneth Snyder, MD, PhD L Nelson Hopkins MD FACS Elad Levy MD MBA FAHA FACS Adnan Siddiqui MD PhD
Plaque Imaging: What It Can Tell Us Kenneth Snyder, MD, PhD L Nelson Hopkins MD FACS Elad Levy MD MBA FAHA FACS Adnan Siddiqui MD PhD Buffalo Disclosure Information FINANCIAL DISCLOSURE: Research and consultant
More informationPost-op Carotid Complications A Nursing Perspective of What to Watch Out for
Post-op Carotid Complications A Nursing Perspective of What to Watch Out for By Kariss Peterson, ARNP Swedish Medical Center Inpatient Neurology Team 1 Post-op Carotid Management Objectives Review the
More informationFelix Vallotton Ball (1899) LDL-C management in Asian diabetes: moderate vs. high intensity statin --- a lesson from EMPATHY study
Felix Vallotton Ball (1899) LDL-C management in Asian diabetes: moderate vs. high intensity statin --- a lesson from EMPATHY study Conflict of interest disclosure None Committee of Scientific Affairs Committee
More informationCarotid stenosis management: CAS or CEA? Yaoguo Yang, Chen Zhong Beijing Anzhen Hospital,China
Carotid stenosis management: CAS or CEA? Yaoguo Yang, Chen Zhong Beijing Anzhen Hospital,China Disclosure Speaker name:... I have the following potential conflicts of interest to report: Consulting Employment
More informationIS CAROTID ULTRASOUND NECESSARY IN THE CLINICAL EVALUATION OF THE ASYMPTOMATIC HOLLENHORST PLAQUE? (AN AMERICAN OPHTHALMOLOGICAL SOCIETY THESIS)
IS CAROTID ULTRASOUND NECESSARY IN THE CLINICAL EVALUATION OF THE ASYMPTOMATIC HOLLENHORST PLAQUE? (AN AMERICAN OPHTHALMOLOGICAL SOCIETY THESIS) By Sophie J. Bakri MD, Ashraf Luqman MD, Bhupesh Pathik
More informationCardiac evaluation for the noncardiac. Nathaen Weitzel MD University of Colorado Denver Dept of Anesthesiology
Cardiac evaluation for the noncardiac patient Nathaen Weitzel MD University of Colorado Denver Dept of Anesthesiology Objectives! Review ACC / AHA guidelines as updated for 2009! Discuss new recommendations
More informationDuplex Criteria for Determination of 50% or Greater Carotid Stenosis
Article Duplex Criteria for Determination of 50% or Greater Carotid Stenosis David G. Neschis, MD, Frank J. Lexa, MD, Julia T. Davis, RN, RVT, Jeffrey P. Carpenter, MD, RVT Recently the North American
More information