The most important recommendations from the 2017 ESVS/ESC guideline on the management of carotid artery disease

Transcription

1 The most important recommendations from the 2017 ESVS/ESC guideline on the management of carotid artery disease GJ de Borst Department of Vascular Surgery

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5 RECOMMENDATION GRADING CRITERIA

6 What is new in the 2017 Guidelines? 1. Evidence update regarding stroke prevention in patients with Asx & Sx carotid disease 2. Evidence for treatment of atherosclerotic vertebral artery disease 3. Selected unresolved issues

7 1. Evidence update regarding stroke prevention in patients with Asx & Sx carotid disease

8 What is new in the 2017 Guidelines? II Identification of high risk for stroke asymptomatic patients on BMT Evidence supporting rapid interventions in recently Sx patients and timing of carotid interventions after intracranial thrombolysis Evidence for patching, shunting, eversion CEA, protamine reversal, treatment of coils/kinks, etc CEA/CAS complications: stroke, hypotension, hypertension, CNI, patch infection, restenosis

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11 Arch Neurol 2003;60:774 Do the facts & figures warrant a 10-fold increase in the performance of carotid surgery in asymptomatic patients? Barnett HJM, Eliasziw M, Meldrum HE, Taylor DW OPINION Asymptomatic Carotid Stenosis: Mainly a Medical Condition J David Spence

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14 Clinical/imaging features that may be associated with an increased risk of stroke on BMT Clinical history of contralateral TIA/stroke RCT, multicentre CT/MRI ipsilateral silent infarction RCT, multicentre Ultrasound imaging MRA stenosis progression (>20%) spontaneous embolisation on TCD impaired cerebral vascular reserve large volume plaques (>80mm 2 ) echolucent plaques large juxta-luminal black area (>8mm 2 ) intra-plaque haemorrhage lipid rich necrotic core RCT, multicentre multicentre meta-analysis multicentre Meta-analysis multicentre meta-analysis meta-analysis

15 Meta-analysis: 30-day stroke/death 2017 ESVS Carotid & Vertebral Guidelines Lexington CREST-1 ACT-1 SPACE-2 Mannheim CEA n=42 CAS n=43 CEA n=587 CAS n=364 CEA n=364 CAS n=1089 CEA n=203 CAS n=197 CEA n=68 CAS n=68 0.0% 0.0% 1.4% 2.5% 1.7% 2.9% 2.0% 2.5% 1.5% 2.9%

16 Some recommendations sound conservative (eg the rather restrictive recommendations for CEA and CAS in asymptomatic carotid stenosis). Some patients and physicians will probably not accept that surgical or endovascular therapy will be denied as long as no symptoms occur. Eckstein EJVES 2017

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18 Timing of CEA/CAS in symptomatic patients Recommendation 40 Class Level When revascularisation is considered in symptomatic patients with 50-99% stenoses, it is recommended that this be performed as soon as possible, preferably within 14 days of symptom onset Recommendation 41 Class Level Patients who are to undergo revascularisation within the first 14 days after symptom onset should undergo carotid endarterectomy, rather than carotid stenting I I A A

19 EVA-3S + SPACE + ICSS 30-day death/stroke CAS CEA p= 0-7 days 9.4% 2.8% p= days 8.1% 3.4% p=0.04 J Vasc Surg 2013

20 Definition of INDEX event NR = not reported Study Inclusion period Definition of timing Brooks NR Event to revascularisation Witt NR NR CAVATAS Randomisation to revascularisation BACASS Symptomatic in the past 3 months Steinbauer NR SAPPHIRE NR EVA-3S Event to revascularisation Randomisation to revascularisation CREST Event to revascularisation Event to randomisation Randomisation to revascularisation SPACE Randomisation to revascularisation ICSS Event to revascularisation Randomisation to revascularisation Felli Symptomatic in the past 3 months Kuliha Event to revascularisation

21 Delay in recent RCTs on CAS vs CEA CAVATAS EVA-3S SPACE ICSS CREST Inclusion Sx / 6 mths Sx > 60/4m Sx >70% Sx >50% /12m Sx/6 mths Time from qualifying even to treatment NA < 14d CAS 20% < 14d CEA 16% NR CAS 35 (15-82) < 14d: 25% CEA 40(18-87 < 14d: 18% CAS CEA

22 2. Evidence for treatment of atherosclerotic vertebral artery disease

23 Vertebral artery disease Recommendation 103 Class Level Asymptomatic vertebral artery atherosclerotic lesions should not be treated by open or endovascular interventions Recommendation 113 Class Level III C Patients with recurrent vertebrobasilar territory symptoms (despite BMT) and who have a 50-99% extracranial VA stenosis may be considered for revascularisation IIb B

24 3. Selected unresolved issues

25 Selected unresolved carotid issues Should accepted risk thresholds for CEA/CAS be reduced from 6% (symptomatic) and 3% (asymptomatic)? Acute stroke patients with tandem lesions undergoing intracranial thrombectomy: staged or deferred CEA/CAS? Relevance of new DWI-MRI lesions after CEA & CAS. Do these contribute towards cognitive decline?

26 Selected unresolved carotid issues Does the location of VA stenoses in symptomatic patients influence decisions regarding intervention or BMT?

27 Paola de Rango