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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Collaborators Meeting 2014
Isrecentcoronarystenting a problem (or an opportunity) for enrolling the patient in the trial?
Valerio Tolva MD, PhD
Istituto Auxologico Italiano IRCCS
Deparment of Surgery
(Head: Renato Casana MD)
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?
“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
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
Do PCI/Open HeartSurgeryaffect the rate of Major AdverseCardiovascularEvents in patient with carotidarterystenosis?
Shishehbor et al. JACC. 2013
Solid line: CAS with PCI
Tomai et al.
Do PCI affect the rate of Major AdverseCardiovascularEvents in patients with carotidarterystenosis?
RELATED COMPLICATIONS: death, MI, stentthrombosis
Van Kuijk et al. Am.J.Cardiol, 2009
SuspensionofDoubleAntiPlateletTherapyafterPercutaneousCoronaryIntervention (PCI) isassociated with the risk of peri-operative Major AdverseCardiovascularEvents due to stentthrombosis
Stentthrombosisis a multifactorialprocess
Surfacecoating: DrugElutingStents (DES), Bare Metal Stents (BMS)
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.
RELATED COMPLICATIONS: Severe bleeding (life-threatening, requiring surgical intervention, transfusion)
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
…Join the Trial and choose the best route