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Carotid surgery past present future

Carotid surgery past present future. J M CARDON PRIVATE HOSPITAL FRANCISCAINES NIMES FRANCE. Now in russia. First cause of mortality cardiac events : 683 170 Second stroke : 372 534 Third cancer: 293 602

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Carotid surgery past present future

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  1. Carotidsurgerypastpresent future J M CARDON PRIVATE HOSPITAL FRANCISCAINES NIMES FRANCE

  2. Now in russia • First cause of mortalitycardiacevents: 683 170 • Second stroke : 372 534 • Third cancer: 293 602 Infografika 2012

  3. The past TCMM 1977 Easton JD 21,1%

  4. And now TCMM Série Historique 1977 Easton 6,5 % 2,8 % 2,8% 2006 EVA 3S 3,9 % NASCET 1991 ACAS 1995 EVA 3 S 2006 15000 cases in France

  5. INDICATIONS4 randomizedstudy • Symptomaticstenoses NASCET 2885 patients 1987-1996 ECST 3024 patients 1981-1994 • Asymptomaticstenoses ACAS 1659 patients 1987-1993 ACST 3125 patients 1995-2003

  6. INDICATIONSsymptomaticstenoses

  7. Symtomaticstenoses Sténoses > 70 % NASCET 2885 patients NEJM 1991 ECST 3024 patients Lancet 1991

  8. Symptomaticstenoses Sténoses 50-69 % NASCET 858 patients NEJM 1998 ECST 646 patients Stroke 2003

  9. symptomaticstenosessome subgroups have more benefit from surgery Age > 75 (Nascet NST 3 vs 6) stroke vs TIA men vs women central vs retineal

  10. symptomaticstenoses Résults of surgeryaccording to delayfromsymptoms No statiscaldifferrence in TCMM

  11. But the sooneris the better Reduction of absoluterisk of stroke and mortalityat 5 yearsaccording to the delay of surgery Rothwell : stroke 2004

  12. INDICATIONS TIA Stroke risk 7 days 10 % 30 days 15 %

  13. TIA is an emergency • Angio MRI or scan in lessthan 24 h • Duplex doppler • Cardiac screening • Hospitalisation if ABCD2 ≥ 3

  14. INDICATIONSasymptomaticstenoses

  15. Randomized controlled trialsCEA vs BMT • ACAS 1995 Jama • ACST-1 2004 Lancet 2010 • Level 1 grade A evidence supporting CEA • In highly selective asymptomatic patents with a stenosis > 60 % CEA conferred a 50 % relative risk reduction of stroke at 5 years

  16. asymptomaticstenoses Sténoses > 60 % ACAS 1662 patients JAMA 1995 ACST 3120 patients Lancet 2004

  17. ACTS – 1 : 10 years

  18. asymptomaticstenoses Subgroupanalysis • Degre of stenosisdoes not influence the results • better for men vs women (↓ r.a 8 / 1,4 %) • benefit arrive after 1 years • younger <75 years have more benefitthanolder

  19. asymptomaticstenoseswhat about best medicaltreatment ?

  20. USA 2005 • Endartériectomie 135 701 • 92 % asymptomatique

  21. With the use of statins in ACTS-1 • The evidence of stroke fell strongly in the medical arm • But it fall strongly as well is the CEA arm. • So the difference is still highly significant

  22. EASY INDICATION SymptomaticAsymptomatique < 50% NASCET < 60% NASCET NO BENEFIT FROM CEA

  23. strong INDICATION SYMPTOMATIcstenoses > 75%

  24. DISCUSSION

  25. In summery : indications • TIA are emergencies • Symptomatic patient have to betreatedwithin 15 days • The degree of stenosisdoes not influence the stroke risk in asymptomatic patient withstenosis >60% • TCMM must be < 3% to operateasymptomatic patient

  26. TECHNICAL EVOLUTION OF CEA

  27. EVERSION Cochrane 2003

  28. TECHNICEversion Notre opinion Pour LESS RESTENOSIS NO CLINICAL BENEFIT SURGEON CHOICE

  29. G

  30. TECHNICPatch versus direct SUTURE 2009

  31. 2009 MAY REDUCE RESTENOSIS AND OCCLUSION RATE REDUCE IPSILATERAL POST OP STROKE RATE REDUCTION IN POST OP TCMM RATE

  32. WHAT PATCH ? Dacron Collagène vs PTFE 2004

  33. CEREBRAL PROTECTION 2009

  34. PER-OP CONTROLDUPLEX SCAN • Avantage : hémodynamic and morphologic • data

  35. per op Angiography comparative study

  36. CONTROLE PER-OPERATOIREAngiographie per-op

  37. Anesthésia STROKE + DEATH +MI 30ème jour GA 4,8 % LA 4.5 % 3526 patients Quality of life (1 month) intervention time ICU stay hospitalstay NO différence

  38. Héparine reversal

  39. no major differrencebetweentecnics but eversion or systematic patch betterthan direct suture • No proof for shunting :never ,sometimes or always • Local or geneneralanesthesia are equivalent • Heparine reversal have no impact on stroke or MI risk

  40. What about CAS ? • NEVER FOR SYMPTOMATIC PATIENT: Eva 3s , space , icss , crest: Risk x 3 comparingwith CEA • Not for old > 80 years • Anatomysuitable for CAS

  41. CAS vs CEA symptomaticstenosemortality or srokeat 30 days

  42. CAS RISK >80 YEARS Registres prospectifs N TCMM Hobson (Crest) 99 12% 2004 Stanziali (Pittsburgh) 87 9,2% 2005 Gray (Capture) 594 7,9% 2006

  43. CAS and asymptomatic > 60% • Equivallencewith CEA in crest • More than 100 CAS experience to getskills • Answerwith ACST 2 study: work in progres

  44. Progres in CAS • 8F Transcervical Arterial Sheath • 8F Venous Return Sheath • Large bore flow reversal circuit • Flow controller with stop, HI and LO flow

  45. Personalactivity CEA CAS • 2010 88 20 • 2011 102 26 • 2012 86 43

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