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Asymptomatic Carotid Surgery Trial ACST-2. Collaborators Meeting 2014 Pembroke College, Oxford Is recent coronary stenting a problem (or an opportunity ) for enrolling the patient in the trial? Valerio Tolva MD, PhD Istituto Auxologico Italiano IRCCS Deparment of Surgery

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asymptomatic carotid surgery trial acst 2

AsymptomaticCarotidSurgery TrialACST-2

Collaborators Meeting 2014

Pembroke College,

Oxford

Isrecentcoronarystenting a problem (or an opportunity) for enrolling the patient in the trial?

Valerio Tolva MD, PhD

Istituto Auxologico Italiano IRCCS

Deparment of Surgery

VascularSurgery

(Head: Renato Casana MD)

Milan, Italy

slide2
Handling a patient with recentcoronarystenting and carotidstenosisislike a sailing race:

You can head straight forcing the upwind : with double therapyperform CAS

You can run on a beamwind and thenupwind : stop double therapy and performCEA

Crewshaveguidelines for the right approach to a race…

can we create guidelinesusing the data of the Trial?

slide3

“the prevalence of severe carotiddisease (>80%% stenosis of ICA) amongpatientsundergoingPercutaneousCoronary Intervention (PCI)/Open HeartSurgery (OHS) isestimated to be 6% to 12%.”

“…optimal treatment of patients with concurrentcarotid and coronaryarterydiseaseremainsunresolveddespite >110 publicationsduring the last 30 years reporting results in 9,000 patients.”

Overview of the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP), from Timaran et al. J VascSurg 2009

slide4

Coronaryrevascularizationbefore non cardiacsurgeryisbelievedtodecrease the peri- and post-operative risk in selectedpatients

Fleisher LA et al. ACC/AHA 2007 Guidelines on perioperativecardiovascularevaluation. J Am CollCardiol 2007

The frequency of major non cardiacsurgery in the yearafterDrugElutingStentplacementis >4-5%

Berger et al. Pre-Operative DES in EVENT Registry. J AmCollCardiolIntv. 2010

Van Kuijk et al. Timing of non cardiacsurgeryaftercoronaryarterystenting. Am J Cardiol 2009

slide5

UnprotectedProtected

Do PCI/Open HeartSurgeryaffect the rate of Major AdverseCardiovascularEvents in patient with carotidarterystenosis?

Shishehbor et al. JACC. 2013

slide6

Dashed line: CAS without PCI

Solid line: CAS with PCI

Tomai et al.

2011. JACC:CardiovascInterv

Do PCI affect the rate of Major AdverseCardiovascularEvents in patients with carotidarterystenosis?

slide7

Why do weconsiderPercutaneousCoronaryIntervention a bias?

CEA withoutDoubleAntiPlateletTherapy

RELATED COMPLICATIONS: death, MI, stentthrombosis

Van Kuijk et al. Am.J.Cardiol, 2009

slide8

SuspensionofDoubleAntiPlateletTherapyafterPercutaneousCoronaryIntervention (PCI) isassociated with the risk of peri-operative Major AdverseCardiovascularEvents due to stentthrombosis

Stentthrombosisis a multifactorialprocess

Surfacecoating: DrugElutingStents (DES), Bare Metal Stents (BMS)

Stentdiameter

Stentlength

Vessel diameter

Left ventricularejectionfraction

Metabolicsyndrome

slide9

Stent-relateddecisionmaking:

PCI with BMS: The European Society of Cardiology + ACC/AHA recommends DAPT for a minimum of 6 weeks after PCI

PCI with DES: The European Society of Cardiology + ACC/AHA recommends DAPT for a minimum of 1 year

Always consider the time interval in patients with coronary and carotid lesions

Avoiding DES in patientsscheduled for carotid or aorticsurgery can save 6-9 months.

The

cardiovascular

crew

slide10

Why do weconsider PCI a bias?

CEA withDoubleAntiPlateletTherapy

RELATED COMPLICATIONS: Severe bleeding (life-threatening, requiring surgical intervention, transfusion)

slide11

Bleeding and DoubleAntiPlateletTherapy

Bleeding and hematoma of the neck are the leadingcauses of in-hospital morbidityaftercarotidsurgery

Major AdverseCardiovascularEvents and bleeding are the mainpredictors for unplanned hospital readmissionwithin 30 days of CEA

Ho KJ et al. Predictors and consequences of unplanned hospital readmission. J VascSurg 2014

a decision making flowchart

Enrollablecarotidstenosis

Recent PCI (< 3 months)

Is DAPT stillrunning?

A decision-making flowchart?

YES

NO

BMS

DES

Symptoms?

Unstableinstrumentalfindings?

Wait 9 months

Wait 3 months from PCI

ENROLL THE PATIENT

CAS

slide13

Keypoints

  • The cut off for enrolling the patientis 3 months.
  • In asymptomaticpatients, cardiac timing is the leadingpriorityregardingcarotidstenosis
  • Carotidendarterectomyis the bias for enrollmentif the patientistaking double therapy
  • As DES and BMS havedifferentsafetyperiods, a tailoredstenting in patients with tandem lesions (coronary and carotid) must be considered.
  • RecruitmentCenters with CathLab can enroll 6-12% of patientsafter PCI (30-60 pts/year)
  • Shouldwe look at thissubgroupor will the trial give the answers?
before making a mistake
Before making a mistake…

…Join the Trial and choose the best route