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Should we continue to perform Carotid Endarterectomy? 2014 Annual Society for Vascular Ultrasound Conference August 7, 2014 Lake Buena Vista, Florida Steven.

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Presentation on theme: "Should we continue to perform Carotid Endarterectomy? 2014 Annual Society for Vascular Ultrasound Conference August 7, 2014 Lake Buena Vista, Florida Steven."— Presentation transcript:

1 Should we continue to perform Carotid Endarterectomy? 2014 Annual Society for Vascular Ultrasound Conference August 7, 2014 Lake Buena Vista, Florida Steven Leers MD, RVT, FSVU

2 Question The first carotid endarterectomy (CEA) was performed in – 1890 – 1910 – 1930 – 1950 – 1970

3 Answer The first carotid endarterectomy (CEA) was performed in – 1890 – 1910 – 1930 – 1950 – 1970

4 C. Miller Fisher MGH In the early 1950s, ischemic stroke attributed to vasospasm/MCA thrombosis Autopsy showed normal MCA 1951 reviewed 8 stroke cases with angiogram and autopsy findings “One day surgeons may even devise a method to remove the offending plaque and thereby prevent stroke” Fisher CM, Occlusion of the internal carotid artery. Arch Neurol and Psychiatry 1951: 65:

5 Beginnings Eastcott HHG, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet 1954; 12:

6 1954 “Mrs. A, a housewife, aged 66 was in bed Dec. 26, 1953, recovering from a cold when she had her first attack. She noticed that she could not use either her right arm or leg and that a film had come over her left eye. She tried to call her son but found she could not speak…Recovery was complete in a few minutes”

7 1954 “The carotid artery was punctured and three injections of contrast was made. The delayed filling of the internal carotid artery was confirmed and was shown to be due to an atheromatous lesion almost occluding the origin of the vessel.” “At the time of her operation she had, in all 33 major attacks lasting from ten minutes to half an hour… Eight of these attacks occurred after her admission to hospital on April 9, 1954.”

8 1954 “On May 19 the patient was anaesthetized by Dr. C.A. Cheatle and her body temperature reduced to 82.4 degrees Fahrenheit by external cooling… The external carotid artery was ligated and the diseased segment of the artery (3cm long) was resected… Originally it was intended to insert a blood-vessel graft, but this proved to be unnecessary, a direct end-to-end anastamosis being performed.” Eastcott HHG, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet 1954; 12:

9 1954 “On return to the ward the patient was gradually warmed; her body temperature had reached 98.6 twelve hours after the induction of anaesthesia… She made a satisfactory recovery…She was walking forty-eight hours after her operation and left hospital on June 2 (surgery 5/19).” Eastcott HHG, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet 1954; 12:

10 Beginnings Originally described by Dr. Debakey although his series was not published until years later. Debakey ME. Successful carotid endarterectomy for cerebrovasacular insufficiency. Nineteen -year follow-up. JAMA 1975: 233:

11 CEA: Pathophysiology CEA never about revascularization, rather the removal of a dynamic disease process wherein dynamic plaque events either have already, or have the potential to cause thromboembolic stroke. Dr. Wesley Moore described the ominous implications and stroke potential of plaque ulceration. Maddison FE, Moore WS. Ulcerated atheroma of the carotid artery; arteriographic appearance. Am J Roentgenol Radiium Ther Nuc Med. 1969: 107:

12 CEA: Pathophysiology Imparato and Wylie recognized subplaque hemorrhage as etiology of CVA Imparato AM, Riles TS. The carotid bifurcation plaque: pathologic findings associated with crebral ischemia. Stroke, 1979: 10: Lusby RJ, Stoney RJ, Wylie EF. Carotid plaque hemorrhage. Its role in production of cerebral ischemia. Arch Surg 1982: 117: Plaque morphology: CT, MR or high resolution ultrasound can predict patients likely to have symptoms Nicolaides AN et al, Asymptomatic Internal carotid artery stenosis and cerebrovascular risk stratification, J Vasc Surg 2010: 52:

13 CEA: Pathophysiology Still high correlation of symptoms with degree of stenosis. Intraplaque hemorrhage correlates with degree of stenosis. Severity of stenosis remains primary indication for CEA

14 Symptomatic disease CEA clearly established as superior to best medical therapy in symptomatic >70% stenosis NASCET Collaborators, 1991 CAS carries higher risk in elderly patients and early post-CVA patients Rantner, JVS 2012 Jim, JVS 2012

15 Medical Management of Carotid Disease Modern antithrombotic and statin therapy has relegated surgery to Symptomatic patients only Surgery for the asymptomatic lesion is inferior to statin therapy in this complex meta-analysis

16 Abbott, Stroke 2009 Studies NOT corrected for threshold level of stenosis (not surgical lesions in the first place) Second Manifestations of ARTerial disease (SMART); less than 50% “surgical lesions” Oxford Vascular Study: 0.34%/year stroke rate – In subgroup of “surgical lesions” 3/32 (10%) had CVA

17 Asymptomatic Disease: Natural History Schillinger, Vienna – >1000 patients followed with duplex scan – 10% progressed over 7 months – 2X stroke rate with progression – 70% of cohort on statins! Sabeti, Stroke 2007 ACSRS (Asymptomatic Carotid Stenosis Risk of Stroke) – >1000 patients with moderate/severe stenosis – Stroke increased with degree of stenosis – 10% CVA rate at 3 years in severe lesions Nicolaides, Eur Jl Vasc Endovasc Surg 2005

18 REACH trial Reduction of Atherothrombosis for Continued Health registry – 3000 patients followed with >70% stenosis. – 1 year risk of stroke 6.5% – Published after Abbott’s meta-analysis Aichner, Eur Jl Neur 2009

19 CEA safety/efficacy Large administrative databases regional and national have all demonstrated safety in a “real world” situation Matsen et al, JVS 2006: California and Maryland Sidawy et al, JVS 2009: SVS registry Goodney et al, JVS 2008: VSGNE Kang et al, JVS 2009: NSQIP 2.2% overall stroke/death rate in 4000 CEA from

20 CAS: The Last Frontier? Cost effectiveness: 9/10 studies show CEA more cost-effective than CAS – Sternbergh et al, JVS 2012; Ochsner Clinic University of Michigan Medicare database study Cardiologists constitute 1/3 of operators but do ½ of procedures CAS likely proceeded by cardiac cath, not TIA/CVA – Berkowitz et al, Arch Intern Med 2011

21 CEA vs CAS International Carotid Stenting Study (ICSS) – Composite endpoint stroke/death/MI – CAS group 8.5%, CEA 5.2%, highly significant CREST trial – 1200 patients randomized to CAS vs CEA Stroke/death rate 4.8% for CAS, 2.6% for CEA Symptomatic: 6% for CAS, 3.2% for CEA 70 year age inflection point increases risk Myocardial infarction more common in CEA

22 CEA vs CAS – California hospital discharge data – Asymptomatic patients – Rigorous risk adjustment and propensity scoring – 6053 CAS, 36,524 CEA – CAS conferred a 2.49 odds ratio of stroke/death over CEA

23 Mayo Clinic Health Policy Research Unit Meta-analysis 2011 study of all randomized trial data Relative stroke risk 1.8, death rate 2.53 for CAS compared to CEA – Murad et al, JVS 2011

24 Conclusions Strong history of scientific thought supports idea of stroke prevention via carotid intervention CEA is safe and effective in symptomatic and high risk patients CEA is superior to best medical treatment even in asymptomatic patients CEA superior to CAS in ALL patient groups

25 THANKS!!


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