Prevention and Management of Cardiac Adverse Event

Transcription

1 Prevention and Management of Cardiac Adverse Event Carlo Cernetti Department of Interventional Cardiology Mirano (Italy) Cannes MEEC 14 June 2007

2

3

4

5

6

7 Are these risks factors of Haemodynamic Instability a limit for Carotid Artery Stenting?

8 High Anatomical and Clinical Risk for CEA congestive heart failure (class III/IV) and/or known severe left ventricular dysfunction LVEF <30% unstable coronary syndromes synchronous severe coronary artery disease requiring carotid and coronary revascularization contralateral laryngeal nerve palsy severe pulmonary disease (FEV < 1.0) Tracheostomy contralateral carotid occlusion post radiation treatment previous CEA recurrent stenosis high cervical ICA lesions or CCA lesions below the clavical, severe tandem lesions = all NASCET excluded patients

9 CEA Limitations >60% have a severe CAD

10 CEA VS CAS: Trop I 75 consecutive PTS CEA TROP I >0,5ng/ml in 13% (P>0.01) FU 5 y: MACE 20% (P<0.1) 75 consecutive PTS CAS TROP I >0,5ng/ml in 1% (P>0.01) FU 5 y: MACE 5% (P<0.1) Motamed C.et al.j Vasc Surg 2005 May;41(5):769-74

11 Combined endpoint death/stroke/mi p = % 5.8% SAPPHIRE

12 Procedural Complications Rates SAPPHIRE

13 Sapphire 1 year Death CAS % CEA % All stroke Major ipsilateral stroke Significant p=0.03 MI Significant p=0.04 Combined MACE Significant p=0.048

14 Cumulative Percentage of Target Lesion Revascularization at 1080 Days SAPPHIRE - Randomized Patients Cumulative % of TLR CEA Stent LR p=0.084 CEA 7.1% Stent 3.0% Time (days) Days: CEA: (90%) 134 (80%) 112 (67%) Stent: (96%) 154 (92%) 139 (83%)

15 Cumulative Percentage of Stroke to 30 Days and Ipsilateral Stroke from 31 to 1080 Days SAPPHIRE: Randomized Patients Cumulative % of Stroke CEA Stent LR p=0.945 Stent 4.9% Stent 6.3% Stent 3.6% CEA 5.8% CEA 6.7% CEA 3.0% Stent 7.1% CEA 6.7% Time (days) 30 Days: CEA: (90%) 134 (80%) 112 (67%) Stent: (96%) 154 (92%) 139 (83%)

16 Indications for carotid artery stenting congestive heart failure (class III/IV) and/or known severe left ventricular dysfunction LVEF <30% unstable coronary syndromes synchronous severe coronary artery disease requiring carotid and coronary revascularization contralateral laryngeal nerve palsy severe pulmonary disease (FEV < 1.0) Tracheostomy contralateral carotid occlusion post radiation treatment previous CEA recurrent stenosis high cervical ICA lesions or CCA lesions below the clavical, severe tandem lesions = all NASCET excluded patients

17 Normal Condition and CAS induced Cardiac and Hemodinamic Instabilty Predilatation-Postdilatation Phases: Arterial Hypotension (SysPAO<90mmHG) Arterial Hypertension (SysPAO>180mmHG) Bradycardia (HR < 60 BMP) Management: Atropine (3mg routinely) Nitrates Dopamine Nitroprusside Dobutamine B-Blockers Temporary P-M (Ao Valve Stenosis) ACE-Inhibitors

18 Condition at High Risk for Cardiac and Hemodinamic Instabilty congestive heart failure (class III/IV) and/or known severe left ventricular dysfunction LVEF <30%; Aortic Valve Stenosis unstable coronary syndromes synchronous severe coronary artery disease requiring carotid and coronary revascularization severe pulmonary disease (FEV < 1.0) contralateral carotid occlusion Very heavy calcification of the bifucation

19 Outcomes Following CEA- CABG Staged CEA-CABG 10 Metaanalysis (97 pubblications) Percent Stroke MI Naylor et al.. Eur J Endovasc Surg 2003, 25: * Huh J, et al. Current Opin Cardiol 2003, 18:

20 Outcomes Following CEA- CABG Reversed Staged CABG-CEA Percent ,3 Metaanalysis (11 pubblications) 2 0 Stroke 0,9 MI Naylor et al.. Eur J Endovasc Surg 2003, 25: * Huh J, et al. Current Opin Cardiol 2003, 18:

21 Outcomes Following CEA- CABG Combined CEA-CABG* CABG* 10 8 Metaanalysis (10 pubblications) Percent 6 4 3,8 3,1 2 0 Stroke MI Naylor et al.. Eur J Endovasc Surg 2003, 25: * Huh J, et al. Current Opin Cardiol 2003, 18:

22 SHARP TRIAL: Simultaneous Hybrid Revascularization by Carotid Stenting and Coronary Artery Bypass Grafting F. Versaci, et al. Ann Thorac Surg 2007, in press Courtesy : Versaci

23 Courtesy : Versaci SHARP TRIAL: Simultaneous Hybrid Revascularization by Carotid Stenting and Coronary Artery Bypass Grafting (International Registry) Principal Investigator : F. Versaci Partecipating Centers Tor Vergata University of Rome: Coordinating Center Ospedale Civile Mirano (B. Reimers,S.Saccà,C,Cernetti) Heart Center Hamburg (J. Schofer,M,Sluter)

24 Courtesy : Versaci Clinical and Procedural Characteristics Patients n 80 Age 70±8.8 Female Unstable Angina 22% 22% Anginal Class III/IV* 72% Bilateral Carotid Stenosis 56% Previous TIA Previous IMA BIMA Grafts (n ) Euroscore Diabetes 25% 25% 19% 3 ±0.8 8 ±4.3 41% * According to the classification system of the Canadian Cardiovascular Society (CCS). Surgical risk expressed as Euroscore (Eur J Cardiothor Surg 1999; 15: ).

25 L. Chiariello, F. Versaci. Ann Thorac Surg 2006 May;81(5): A NEW HYBRIDE APPROACH Combined Carotid Artery Stenting and CABG Treatment Protocol CAS CABG (simultaneous) 6 hrs GPo n. 1 (for 30 days) > 30 days Heparin Plavix 300 mg 1 mg/kg for CAS (no bleeding) 2 mg/kg for CABG Plavix 75 mg + Cardioaspiri n Cardioaspiri n

26 Combined Carotid Artery Stenting and CABG N. pts 80 Clinical Outcomes within 30 days Mortality Stroke 2 (2.5%) 1(1.2%) MI - F. Versaci, et al. Stroke, in press

27 Carotid stenting may sometimes be a very challenging intervention, n, not only due to anatomical and/or lesion complexities, but also for the patient general status (haemodynamic( instability, renal failure, pulmonary disease, etc.). For these reasons, we consider mandatory the following technical equipment Cath Lab Invasive and non-invasive vital parameters monitoring, Emergency life supports Devices (ventilator, defibrillator, IABP,temporary pace- Maker). Medication

28 Continuos ECG and invasive pressure monitoring!!! mmhg 150 Aortic pressure CCA pressure Occlusion of balloon in CCA stump pressure

29 Cardiac Complication during CAS: The Cardiologic Enviroment Planned CAS Coronary Unknown Disease Courtesy: : J Schofer

30 Cardiac Complication during CAS: The Cardiologic Enviroment Planned CAS Coronary Unknown Disease Chest Pain and ST elevation!! Courtesy: : J Schofer

31 Incidence of hemodynamic complications Qureshi AL et al. Stroke 1999;30:

32 Incidence of hemodynamic complications Qureshi AL et al. Stroke 1999;30:

33 Incidence of hemodynamic complications Qureshi AL et al. Stroke 1999;30:

34 Incidence of hemodynamic complications Qureshi AL et al. Stroke 1999;30:

35 Incidence of hemodynamic complications Qureshi AL et al. Stroke 1999;30:

36 Incidence of hemodynamic complications Trocciola S.M. AL et Abstact book

37 Incidence of hemodynamic complications 111 PTS CAS Procedure 11 (9.6%) required a Temporary PM Wholey et al J Endovasc Surg 1997;4:326

38 Incidence of hemodynamic complications 107 PTS CAS Procedure 71% 5±3 min Bradycardia after Postdilataton of the stent 1 Pz required permanent PM Yadav JS Circulation1997;95:376

39 Hyperperfusion Syndrome Clinical symptoms: confusion, headache, seizures Treatment Low BP ACT<200sec Corticosteroids Antiepileptic drugs Surgery (Haematoma) Cerebral edema and hemorrhage

40 Hyperperfusion Syndrome Clinical symptoms: confusion, headache, seizures Elderly Blood pressure control History of stroke Severe hemodynamically significant stenosis Severe stenosis with contralateral occlusion String-sign

41 Conclusion Hemodynamic and Cardiac Instability is a frequent consequence of carotid artery revascularization CAS is superior than CEA in preventing Hemodynamical and Cardiac complication Nevertheless CAS must be performed in correct setting and with a good clinical selection of the Patients

42 Hemodynamic and Cardiac Instability is something dangerous!!!! Better to Prevent it before is too late!!

43

44 Talk about Hyperperfusion syndrome: presence or absence of isolated hemisfere Elderly and Protection form Hyperperfusion Syndrome: maintanance of th PTS in Inensive care It can occur after 3,7 days after cas or tea