ASYMPTOMATIC CAROTID STENOSIS WE CAN (AND SHOULD) CHOOSE PATIENTS FOR ASYMPTOMATIC CAROTID STENOSIS TREATMENT BASED ON SURVIVAL PREDICTIONS

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1 WE CAN (AND SHOULD) CHOOSE PATIENTS FOR ASYMPTOMATIC CAROTID STENOSIS TREATMENT BASED ON S ASYMPTOMATIC CAROTID STENOSIS TREATMENT BASED ON DISCLOSURES INDIVIDUAL None A patient with an asymptomatic 90% carotid stenosis should not undergo intervention unless his/her life expectancy is INSTITUTIONAL Cook, Inc Not discussing off label anything 1. 1 year or more 2. 2 years or more 3. 5 years or more 13% 22% 65% 1 y e a r o r m... 2 y e a r s o r... 5 y e a r s o r... 1

2 An 82-year old patient with a 90% left carotid stenosis is referred to you. He underwent CABG 6 years ago and is asymptomatic. He no longer smokes. He does not take a statin because he developed muscle pain. His Cr is 1.6 mg/dl. He is not diabetic. He plays golf twice a week and either walks a mile or swims for 30 minutes on days he does not play golf. He just returned from a golf vacation 70% in Scotland. 1. CEA 2. CAS 3. BMT 5% 25% DECISION ANALYSIS Stroke risk Symptom status Degree of stenosis Plaque morphology Stenosis progression Treatment benefit Long-term survival C E A C A S B M T TREATMENT RECOMMENDATIONS CEA should be considered for asymptomatic stenosis of 60-99% because it lowers risk of stroke by a small but statistically significant amount (LEVEL 1) CEA is of benefit only if it can be performed with a complication rate of 3% (LEVEL 1) CEA primarily benefits men and those with a life expectancy of 5 years (LEVEL 1) CAS may be considered as an alternative to CEA if CEA would present special difficulties and CAS can be performed with a complication rate 3% (LEVEL 2b) CONTROVERSIES Studies not optimally designed Degree of stenosis Definition of asymptomatic Definition of primary endpoints Best medical therapy then best medical therapy now Change in treatment options (CAS) affects the risk / benefit balance 2

3 TREATMENT RECOMMENDATIONS CEA should be considered for asymptomatic stenosis of 60-99% because it lowers risk of stroke by a small but statistically significant amount (LEVEL 1) CEA is of benefit only if it can be performed with a complication rate of 3% (LEVEL 1) CEA primarily benefits men and those with a life expectancy of 5 years (LEVEL 1) CAS may be considered as an alternative to CEA if CEA would present special difficulties and CAS can be performed with a complication rate 3% (LEVEL 2b) Conrad et al, Ann Surg 2013 Patients 1791 CEA Day CVA 1.1% 30 Day ipsi 0.8% CVA 30 Day death 0.7% 5-Year actual 73% survival Age 1.8 CAD 1.5 COPD 2.5 Diabetes 1.7 Neck XRT 2.6 No statin 2.1 Cr > Conrad et al SCORE 5-YR SURVIVAL (%) 0 to to to to Wallaert et al, JVS 2013 Patients 4114 CEA Day CVA 30 Day ipsi CVA 30 Day death 5-Year actual 82% survival Age CHF 1.78 COPD 1.66 Diabetes Smoking hx 1.68 No statin 1.27 Renal fx Contralateral stenosis 3

4 Wallaert et al, JVS 2013 Wallaert et al, JVS 2013 Hemodynamic instability 54% Evidence of infection 44% Need for adjunctive procedures Intestinal repair 20% other 32% Lifetime antibiotic treatment 44% Antoniou, J Vasc Surg, 2009 Wallaert et al, JVS 2013 Alcocer et al, JVS 2013 Patients 506 CEA Day CVA 2.2% 30 Day ipsi CVA 30 Day death 1.0% 3-Year actual 86% survival Age 1.79 CAD Rx 2.03 COPD 3.53 Diabetes 1.99 Dialysis 5.67 Severe CKD

5 Alcocer et al, JVS 2013 OUTCOMES HIGH-RISK ASX CEA SCORE 3-YR MORTALITY 2 6.1% > % Wallaert et al. Stroke 2012 OUTCOMES HIGH-RISK ASX CEA OUTCOMES HIGH-RISK ASX CEA Varied aortic pathology Primary 27% atherosclerotic 14% tumor 10% trauma 3% Secondary 73% after prior aortic graft Wallaert et al, Stroke, 2012 Wallaert et al, Stroke,

6 CLE = P (1 P) r 0 r 1 CLE = critical life expectancy P = probability of periprocedural stroke r 0 = annual stroke rate without intervention r 1 = annual stroke rate after intervention Yuo et al, Medical Decision Making, 2013 SCENARIO P r 0 r 1 CLE ACAS (1995) ACST (2004) CREST (2010) Guidelines & BMT OUR PATIENT STUDY SCORE SURVIVAL TREAT Conrad et al NO Wallaert et al medium 80.0 YES Alcocer et al MAYBE CAN WE USE SURVIVAL PREDICTION TO GUIDE TREATMENT YES 6

7 SHOULD WE USE SURVIVAL PREDICTION TO GUIDE TREATMENT HOW DO WE USE SURVIVAL PREDICTION TO GUIDE TREATMENT YES HOW DO WE USE SURVIVAL PREDICTION TO GUIDE TREATMENT We must beware of needless innovation, especially when guided by logic. Winston Churchill 7

8 STUDY Duschek et al FACTOR age NT pro-bnp 8