Marvin D. Atkins, Jr., MD Division of Vascular Surgery Temple, Texas, USA April 2011

1. Carotid Artery Occlusive Disease Update 2011 • Marvin D. Atkins, Jr., MD • Division of Vascular Surgery • Temple, Texas, USA • April 2011

2. Stroke in the United States • Third leading cause of adult death and leading cause of Neurologic Disability in the United States. • Approximately 750,000 new cases per year. • Annual Cost ~$40,000,000,000 • Framingham Study – 88% ischemic, 9% intracerebral hemorrhage, and 3% SAH • Estimated that 30% of ischemic strokes are related to carotid disease.

3. Carotid Surgery • Carotid artery occlusive disease is the most readily treatable lesion leading to stroke. • Carotid endarterectomy is the most common operative procedure in peripheral vascular surgery.

4. Carotid Occlusive Disease

5. Other Causes

6. Distribution of atherosclerotic occlusive lesions

7. Carotid Plaque and Embolization

9. Carotid Plaque

10. PATIENT PRESENTATION • Asymptomatic cervical bruit. • Transient hemispheric neurologic deficit • Transient monocular dysfunction (amaurosisfugax). • Stroke with or without residual deficit. • Acute stroke or stroke in evolution.

11. Carotid Bruits

12. Surgical Emergencies Crescendo TIA: escalating frequency with resolution between. Stroke in evolution: Waxing and waning symptoms without complete resolution between. • Urgent surgical treatment: improved results with complete recovery in up to 70%.

13. Completed Stroke • Decision to evaluate best determined by whether another stroke in same distribution would likely impair patient substantially beyond current level • For small strokes and resolved deficits, surgery can be done sooner than has been recommended in past.

14. Most of these symptoms are more likely to be a manifestation of cardiac arrhythmias, seizures, migraine, or other non-vascular-related conditions

15. Screening Recommendations

16. Recently published intersociety guidelines JACC

17. Class I • Known or suspected carotid disease – • Ultrasound (US) recommended as first line screening test • Class 2a • US is reasonable in asymptomatic pts w/ bruit • Annual US in those with >50% stenosis • Class 2b • US may be reasonable in those with CAD, AAA, or PVD • Class 3 • Not recommended in asymptomatic pts without risk factors

18. Medical Management: Recommendations

19. Smoking Cessation • Statin is recommended for all pts with carotid dz to • lower LDL < 100 (Class 1, level B), possibly even • < 70 (Class 2A, level B) • HTN – below 140/90 • Control of Diabetes to Hba1C < 7 • Antiplatelet recommendations :

21. Practical Recommendations: • Aspirin as first line therapy • - 325mg for larger patients, 81mg for small pts or those complaining of bleeding/bruising. • Increase antiplatelet regimen if symptoms develop • Add Aggrenox (ASA 25mg/Dipyridamole 200mg) BID • or Plavix 75mg QD • Do Not stop antiplatelet agents prior to CEA. • - Add statin (Lipitor > Pravachol or Zocor) • Ok to stop if asymptomatic prior to another procedure. Restart as soon as possible.

22. Surgical Management: Evaluation

23. Patient Evaluation

24. EVALUATION TECHNIQUES • Search for arterial lesions, coagulopathy, sources for emboli. • Duplex imaging. • Brain imaging - CT or MRI to determine areas of cerebral damage or alternative pathology, i.e. tumors, aneurysms, vascular malformations, etc. • CT Angiography • MR Angiography • Contrast angiography

25. EVALUATION TECHNIQUES Duplex Imaging • B-mode ultrasound combined with spectral analysis of flow velocities determined by doppleridentifies: • Degree of stenosis • Plaque morphology and surface characteristics • *** Plaque surface characteristics may be more significant than degree of stenosis in determining risk for cerebral vascular events.

26. Carotid Duplex Imaging

27. Unstable Plaque Surfaces

28. Duplex Criteria for Native Carotid Lesions

29. Ulcerative Plaque Characteristics *** Other high risk ultrasound findings include : ulcers, intraplaque hemorrhage, intraluminal thrombus or debris, intimal flaps or dissections.

30. Ulcerative Plaque By Duplex Ultrasound

31. IntraplaqueHemorrhage: High risk for fibrous cap rupture, embolism and neurological symptoms.

32. Complex Irregular Plaque By Duplex Ultrasound

33. Contrast Angiography: • “Gold Standard” for anatomical detail • Provides information about tandem atherosclerotic disease, plaque morphology, and collateral circulation. • Invasive procedure • 0.1-1% stroke rate with angiogram alone during NASCET and ACAS trials.

34. MR Angiography: • Non invasive • MRI Contrast contraindicated with impaired renal function • Does not provide bony anatomical detail useful in surgical planning • No pacemakers, etc

35. CT Angiogram: • High resolution anatomical detail with good bone and calcium definition. • Iodinated contrast load can be similar to conventional angiography. • 3-D imaging requires post scanning production to create images.

36. Estimating Stenosis

37. Endarterectomy Trials

38. Symptomatic Carotid Stenosis: NASCET Trial 659 Pts, 50 centers: TIA, Afx, Non-Disabling CVA within 6 months: Best Med vs CEA + best Med Perioperative stroke/death rate = 5.8%

39. Asymptomatic Carotid Stenosis: ACAS Trial 1662 Pts, 39 centers: Asymptomatic Carotid Stenosis > 60% Best Med vs. Best Med plus CEA. Outcomes: ipsilateral CVA or any CVA or death • Over half periop events related to angiogram • Conclusion: CEA for ASX stenosis > 60% justified with careful technique and patient selection.

40. Long-term Risk of Stroke

41. Operative Risk and Stroke Prevention

42. CREST Study Design • Prospective, multicenter, randomized, controlled trial with blinded endpoint adjudication. • Comparing CEA and CAS in participants with symptomatic and asymptomatic stenosis • 108 US and 9 Canadian sites • Team included neurologist, interventionalist, surgeon, and research coordinator at each center. • NEJM May, 2010.

43. CREST: Patient Characteristics

44. CREST Primary Endpoint • Peri-procedural (a composite of): • any Clinical Stroke • Myocardial infarction • Death • Post-procedural • Ipsilateral stroke up to 4 years

45. An acute neurological ischemic event of at least 24 hours duration with focal signs and symptoms. Adjudicated by at least two neurologists blinded to treatment CREST: Stroke

46. Combination: Elevation of cardiac enzymes (CK-MB or troponin) to a value 2 or more times the individual clinical center's laboratory upper limit of normal. Plus Chest pain or equivalent symptoms consistent with myocardial ischemia, or, ECG evidence of ischemia including new ST segment depression or elevation > 1mm in 2 or more contiguous leads Not enzyme-only Adjudicated by two cardiologists blinded to treatment CREST: Myocardial Infarction

47. Primary Endpoint: peri-procedural components (any death, stroke, or MI within peri-procedural period)

48. Peri-procedural Stroke and MI

49. Peri-procedural Stroke • “The quality of life analysis among survivors at one year in our trial indicate that stroke had a greater adverse effect on a broad range of health-status domains than did myocardial infarction”

50. Ipsilateral Stroke after Peri-procedural Period ≤ 4 years