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R Pini

Impact of Acute Cerebral Ischemic Lesions and their Volume on the Revascularization Outcome of Symptomatic Carotid Stenosis. R Pini. Vascular Surgery University of Bologna, Italy Alma Mater Studiorum. Background.

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R Pini

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  1. Impact of Acute Cerebral Ischemic Lesions and their Volumeon the Revascularization Outcome of Symptomatic Carotid Stenosis • R Pini Vascular Surgery University of Bologna, Italy Alma Mater Studiorum

  2. Background • Prompt carotid revascularization is recommended after neurological symptoms in order to avoid early recurrence • Type of symptoms seems to influence complication rate in this setting Alma Mater Studiorum University of Bologna, Italy

  3. Background Summary of Evidence on EarlyCarotidIntervention for RecentlySymptomaticStenosisBased on Meta-Analysis of CurrentRisks Post-op stroke % De Rango et al, Stroke 2015 Preoperative symptoms Alma Mater Studiorum University of Bologna, Italy

  4. Background Outcome of carotid revascularization 20% Reason for this high variability? Post-op stroke % 0% De Rango et al, Stroke 2015 Alma Mater Studiorum University of Bologna, Italy

  5. Can the presence and volume of cerebral ischemic lesions predict the carotid revascularization otcome?

  6. Background • The influence of cerebral lesions on revascularization outcome according to their size has not been studied effectively in the literature • Can the presence and extension of a cerebral lesion give a more accurate risk stratification? Alma Mater Studiorum University of Bologna, Italy

  7. J Vasc Surg 2017; 65: 390-7 To evaluate the impact of cerebral lesions and their volume on carotid revascularization outcome Alma Mater Studiorum University of Bologna, Italy

  8. Methods • Retrospective review of all patients submitted to carotid revascularization (CEA and CAS) for symptomatic carotid stenosis (2005-2014) • Evaluation of ipsilateral preoperative cerebral ischemic lesion (CIL) Alma Mater Studiorum University of Bologna, Italy

  9. Methods Preoperative Cerebral Ischemic Lesion (CIL) • Preoperative computed tomography (CT) • Ipsilateral Embolic (Steven’s Classification) • Volume evaluation (mm3 - multi-planar evaluation) Alma Mater Studiorum University of Bologna, Italy

  10. Volume: an easy calculation ABC/2for rapid clinical estimate of infarct, perfusion, and mismatch volumes Sims et al. Neurology 2009

  11. Methods Exclusion Criteria • No preoperative cerebral imaging • Crescendo TIA • Stroke in evolution Alma Mater Studiorum University of Bologna, Italy

  12. Methods Univariate analysis • χ2 • comparison of outcome in patients with and without CIL • Mann-Whitthney U test • comparison of preoperative CIL volume in patients with post-op stroke • Pearson’s correlation • correlation between CIL-volume and type and timing of carotid revascularization Alma Mater Studiorum University of Bologna, Italy

  13. Methods Multivariate analysis • CIL-Volume cut-off multiple evaluations of values closest to the median CIL-volume • Multiple logistic regression identification of independent risk factors for stroke • ROC curve evaluation of sensibility and specificity of the volume cut-off identified Alma Mater Studiorum University of Bologna, Italy

  14. Results Total pts # 489 (CIL # 251 - 51.4%) Alma Mater Studiorum University of Bologna, Italy

  15. Results Epidemiology Alma Mater Studiorum University of Bologna, Italy

  16. Results Preoperative Symptoms Alma Mater Studiorum University of Bologna, Italy

  17. Results Revascularization outcome Alma Mater Studiorum University of Bologna, Italy

  18. Results Revascularization outcome Alma Mater Studiorum University of Bologna, Italy

  19. Results Revascularization outcome Alma Mater Studiorum University of Bologna, Italy

  20. Results Revascularization outcome Alma Mater Studiorum University of Bologna, Italy

  21. Results CIL volume evaluation Total median = 1000 mm3(IQR 7000mm3) P=.01 No events Postop stroke Alma Mater Studiorum University of Bologna, Italy

  22. Results CIL volume evaluation P=.03 No events Postop stroke/death Alma Mater Studiorum University of Bologna, Italy

  23. Results: CIL volume evaluation ROC curve CIL-vol>4000mm3 Area = .68 P = .02 Sensitivity = .75 Specificity = .63 Youden J statistic

  24. Results CIL volume evaluation • CIL-volume cut-off (value of third IQR): 4000 mm3 Alma Mater Studiorum University of Bologna, Italy

  25. Results CIL volume vs. stroke P=.01 OR: 5.1 95% CI: 1.3-19.5 % Alma Mater Studiorum University of Bologna, Italy

  26. Results Multivariate analysis for risk of stroke Alma Mater Studiorum University of Bologna, Italy

  27. Literature review: CIL effect on carotid revascularization

  28. Literature review: CIL effect on carotid revascularization No studies on the volume of cerebral ischemic lesions

  29. Conclusions • The presence of Ischemic Cerebral Lesion(CIL) does not affect CEA/CAS outcomes • CIL volume >4000 mm3, higher post-operative stroke risk

  30. Conclusions The cerebral damage needs to be investigated for the carotid revascularization for risk stratification

  31. Prospective Patient with CIL< 4000 mm3 can be revascularized without significant higher perioperative risk

  32. Implications ABCD2 score CIL> 4000 mm3 higher risk(9%) independently from timing High risk stenosis (ABCD2-score): Early revascularization? Low risk stenosis: Wait and see?

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