CardioLucca2014. Fare luce sulla scelta ottimale del trattamento nella rivascolarizzazione delle stenosi carotidee. Fabrizio Tomai

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1 CardioLucca2014 Fare luce sulla scelta ottimale del trattamento nella rivascolarizzazione delle stenosi carotidee Fabrizio Tomai European Hospital e Aurelia Hospital Roma

2 Treatment of Carotid Artery Disease Medical therapy: all patients Carotid Revascularization: Symptomatic vs Asymptomatic pts

3 Surgery vs. Medical therapy 30 Symptomatic Asymptomatic Risk of Stroke (%) NASCET ACAS ASA Surgery NASCET trial Ferguson GG et al Stroke 1999; ACAS trial Young B et al Stroke 1996

4 Risk of Stroke in patients with Symptomatic Carotid Stenosis Risk of stroke early after a TIA 16 % N= pts 14 Meta-analysis of 18 studies day 7 day 30 day Days after TIA Giles MF et al., Lancet 2007

5 % 5 4 Risk of Stroke in pts with Asymptomatic Carotid Stenosis on Best Medical Treatment Stenosis severity % 50-79% 50-99% 60-99% 70-99% 75-99% 80-99% 90-99% Naylor AR. Eur J Vasc Endovasc Surg 2009

6 Stroke risk in pts with Carotid Stenosis Plaque morphology Freedom from Stroke (%) Homogenous Group Heterogenous Group 10 Entry >48 Time in Months AbuRahma AF et al. J Vasc Surg 2002

7 Stroke risk in pts with Asymptomatic Carotid Stenosis Plaque morphology Ulcerated plaque Soft plaque Stenosis progression

8 Patients with Asymptomatic Carotid Stenosis Brain imaging (NMR, CT, TCE) Asymptomatic carotid stenosis accounts for a large burden of stroke Only 15% of strokes are preceded by TIA

9 Treatment of Carotid Artery Disease Medical therapy: all patients Carotid Revascularization: Stenting vs Endarterectomy

10 Carotid Revascularization Endoarterectomy vs Stenting Trial Primary endpoint: any stroke, myocardial infarction, or death within 30 days plus subsequent ipsilateral stroke Primary endpoint < 4 yrs (%) 10 p= CAS (1262) CEA (1240) 2502 pts with either symptomatic or asymptomatic carotid stenosis Brott TG et al. N Engl J Med 2010

11 Carotid Revascularization Endoarterectomy vs Stenting Trial % Periprocedural Period (30-day period after the procedure) 0.01 CAS (1262 pts) 0.01 CEA (1240 pts) Death Stroke Major Stroke Brott TG et al. N Engl J Med 2010 Minor Stroke Major Ipsilateral Major Nonipsilateral Minor Ipsilateral Minor Nonipsilateral MI Primary Endpoint

12 * * fatal or disabling stroke Bonati LH et al, Lancet 2014

13 N= pts (propensity matched) Bangalore S. et al, Circulation 2010

14 Selection of revascularization techniques for patients with carotid artery stenosis Guidelines ACCF/AHA/ASA/SCAI/SVS JACC, Circulation 2011 Updated AHA/ASA Stroke 2014 ESC European Heart J 2011 SVS J Vasc Surg 2008 ESVS Symptomatic Carotid Stenosis >50% CEA IA CAS* IB (IIa B ) CEA I A CAS IIa B** CEA 1/HQE CAS** 2/LQE CEA A Asymptomatic Carotid Stenosis >60/70% CEA*** IIa A CAS** IIa B CEA*** IIa A CAS IIb B CEA*** 1/HQE CEA*** A - Eur J Vasc Endovasc Surg 2009 CAS C CAS C *Low endovascular risk **High surgical risk ***Perioperative death/stroke risk<3% RCT, high volume centre, low endovascular risk IIa: Should be considered IIb: May be considered

15 CAS vs CEA: careful evaluation of pts variables by a multidisciplinary team Patient clinical profile - Age - Symptoms - Co-morbidities (CAD, COPD) - Blood tests (TC, Creat, CRP) - Medical therapy Carotid plaque profile - % stenosis, length, morphology - Echo-analysis Vascular profile - Lesion site characteristics (lesion/bifurc) - Aortic arch and supra-aortic vessels - Access details

16 Selection of revascularization techniques for pts with carotid artery stenosis: high surgical risk criteria Clinical criteria Age >75 years Anatomical criteria High Cervical lesion (at or above C2) CCS Class 3-4 or unstable angina Tandem lesion >70% NYHA Class III-IV LVEF<35% MI <6 weeks Controlateral laryngeal palsy Severe intracranial stenosis CEA restenosis Multivessel coronary artery disease Controlateral ICA occlusion Several renal impairment Several pulmonary disease Controlateral cranial nerve injury Hostile neck (prior irradiation, tracheostomy, radial neck dissection) Cervical immobility Planned CABG or valve repl. <60 d Cremonesi A et al. EuroIntervention 2010

17 Selection of revascularization techniques for pts with carotid artery stenosis: high endovascular risk criteria Addressing challenges Aortic arch: Lesion anatomy: Vessel anatomy: Lesion characteristics: Plaque composition: III angled severely tortuous angled, severely calcified, high grade, sub-occlusive dis-homogeneous, soft, ulcerated Cremonesi A et al. EuroIntervention 2010

18 .. Shishehbor MH et al. JACC Card Intv 2014

19 Shishehbor MH et al. JACC Card Intv 2014

20 Tomai F et al. EuroIntervention 2014 CAS (dashed line) vs. CEA (solid line), p=0.99

21 Carotid Artery Revascularization Conclusions Multidisciplinary team approach Centre experience Stroke risk estimation (mainly in asymptomatic patients) Peri-procedural (endovascular vs surgical) risk evaluation: High endovascular risk: CEA favored High surgical risk: CAS favored High endovascular and surgical risks: Medical Tx favored

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