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Eric Hager, MD Assistant Professor of Surgery Division of Vascular surgery University of Pittsburgh Medical Center 1.

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Presentation on theme: "Eric Hager, MD Assistant Professor of Surgery Division of Vascular surgery University of Pittsburgh Medical Center 1."— Presentation transcript:

1 Eric Hager, MD Assistant Professor of Surgery Division of Vascular surgery University of Pittsburgh Medical Center 1

2  3 rd leading cause of death in the United States  Incidence: 795,000  First stroke: 610,000  Recurrent stroke: 185,000  Annual US mortality: 136,000  Morbidity  15-30% permanently disabled  20% require institutional care at 3 months Sources: Roger VL, et al. `American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics update: a report from the American Heart Association. Circulation Feb 1;123(4):e18-e209. Epub 2010 Dec 15. 2

3  Lifetime risk for stroke at 65 years of age  Men: 14.5%  Women: 16.1%  Economic  2007 direct and indirect cost of stroke: $40.9 billion  Average lifetime cost of ischemic stroke: $140,048 Sources: Roger VL, et al. `American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics update: a report from the American Heart Association. Circulation Feb 1;123(4):e18-e209. Epub 2010 Dec 15. 3

4 Hemorrhagic: 13% Ischemic: 87% Source: Mackey WC. CHAPTER 92 – Cerebrovascular Disease : General Considerations. Rutherford’s Vascular Surgery. 7 th Edition

5  Symptomatic disease  Already experienced a neurologic event  High risk of recurrence  Secondary prevention  Asymptomatic disease  Incidentally found  Low, but significant, ongoing risk of an event  Primary prevention 5

6 6 Davis SM, Donnan GA. Secondary Prevention after Ischemic Stroke or Transient Ischemic Attack. N Engl J Med 2012;366:

7  Risk factors:  Male gender  Advancing age  Hypertension  Smoking  Diabetes  Atrial fibrillation  History of cerebrovascular disease 7

8 8  What is the Natural History of carotid disease?  Asymptomatic?  Symptomatic? ▪ * No contemporary studies  non-medically managed  best medical therapy (BMT)

9  1986: 500 patients with asymptomatic carotid bruits and variable stenosis graded by ultrasound  Recorded TIA/Stroke rates  Study period 4 years (mean follow up 26 month) 9 Sources: Chambers BR. Norris JW. Outcome in patients with asymptomatic neck bruits. N Engl J Med. 1986;3 15: % 5.7% 19.5%

10  1987: 296 patients evaluated  Stratified according to: ▪ 1) Degree of stenosis by B-mode US ▪ 2) Echogenicity of the carotid lesion ▪ Gray-scale median >32 =dense ▪ Gray-scale median <32 = echolucent  Evaluated neurologic events over a 3 year study period 10 Sources: O’Holleran LW, Kennelly MM, McClurken M, Johnson JM. Natural history of asymptomatic carotid plaque. Am J Surg. 1987; 154:

11  1987: 296 patients evaluated  Stratified according to: ▪ 1) Degree of stenosis by B-mode US ▪ 2) Echogenicity of the carotid lesion ▪ Gray-scale median >32 =dense ▪ Gray-scale median <32 = echolucent  Evaluated neurologic events over a 3 year study period 11 Sources: O’Holleran LW, Kennelly MM, McClurken M, Johnson JM. Natural history of asymptomatic carotid plaque. Am J Surg. 1987; 154: Support to the NEJM data – degree of stenosis correlates to neurologic event rates. Dense (calcified) plaque is less likely to cause TIA/strokes

12  1984: Stroke - Roederer and colleagues examined 167 patients with <80% stenosis  Conclusion: Progressive disease leads to a higher risk of neurologic events 12 Sources: Roederer GO, Langlois YE, Jager KA, Primozich JF, Beach KW, Phillips DJ, Strandness DE Jr. The natural history of carotid arterial disease in asymptomatic patients with cervical bruits. Stroke 1984;15: Stroke risk at 12 months Stable <80% stenosis1.5% Progressive stenosis >80 %46%

13  Evolution of Best Medical Therapy (BMT)  Smoking cessation  Glycemic control  Anti-platelet (e.g., aspirin +/- dipyridamole, clopidogrel)  Lower hypertension (ACE, ARB,  -blocker)  Address dyslipidemia (statins) 13

14 14 StudyDegree of stenosis YearNumber of patients EndpointStroke or TIA (%) Asymptomatic Carotid Atherosclerosis Study (ACAS)

15 15 StudyDegree of stenosis YearNumber of patients EndpointStroke or TIA (%) Asymptomatic Carotid Atherosclerosis Study (ACAS) 60-99% Ipsilateral stroke 11.0% over 5 years

16 16 StudyDegree of stenosis YearNumber of patients EndpointStroke or TIA (%) Asymptomatic Carotid Atherosclerosis Study (ACAS) 60-99% Ipsilateral stroke 11.0% over 5 years Asymptomatic Carotid Stenosis Trial (ACST)

17 17 StudyDegree of stenosis YearNumber of patients EndpointStroke or TIA (%) Asymptomatic Carotid Atherosclerosis Study (ACAS) 60-99% Ipsilateral stroke 11.0% over 5 years Asymptomatic Carotid Stenosis Trial (ACST) 60-99% Any stroke11.8% over 5 years

18 Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, Thomas D; MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet May 8;363(9420):  Patients with >60% stenosis a) 30 day results:  CEA: 2.5%  BMT: 0.7% b) 5 year results:  CEA: 6.4%  BMT: 11.8%  P< Years after randomization CEA Medical 18

19  No randomized study is possible today in symptomatic disease  Consequently natural history is based on early observational studies 19

20 20 Sources: 1) The Canadian Cooperative Study Group. A randomized trial of aspirin and sulfinpyrazone in threatened stroke. N Engl J Med 299: 53-59, ) Candelise L, Landi G, Perrone P, Bracchi M and Brambilla G. A randomized trial of aspirin and sulfinpyrazone in patients with TIA. Stroke. 1982;13: ) Fields WS, Lemak NA, Frankowski RF, Hardy RJ: Controlled trial of aspirin in cerebral ischemia. Stroke. 8: ) Bousser MG, Eschwege E, Haguenau M, et al.: “AICLA” controlled trial of aspirin and dipyridamole in secondary prevention of athero-thrombotic cerebral ischemia. Stroke. 14: StudyYearNumber of patients Mean follow- up period Stroke or death risk Canadian Cooperative Study Candelise et al. Fields et al. Bousser et al.

21 21 Sources: 1) The Canadian Cooperative Study Group. A randomized trial of aspirin and sulfinpyrazone in threatened stroke. N Engl J Med 299: 53-59, ) Candelise L, Landi G, Perrone P, Bracchi M and Brambilla G. A randomized trial of aspirin and sulfinpyrazone in patients with TIA. Stroke. 1982;13: ) Fields WS, Lemak NA, Frankowski RF, Hardy RJ: Controlled trial of aspirin in cerebral ischemia. Stroke. 8: ) Bousser MG, Eschwege E, Haguenau M, et al.: “AICLA” controlled trial of aspirin and dipyridamole in secondary prevention of athero-thrombotic cerebral ischemia. Stroke. 14: StudyYearNumber of patients Mean follow- up period Stroke or death risk Canadian Cooperative Study 1978 Candelise et al.1982 Fields et al.1977 Bousser et al.1983

22 22 Sources: 1) The Canadian Cooperative Study Group. A randomized trial of aspirin and sulfinpyrazone in threatened stroke. N Engl J Med 299: 53-59, ) Candelise L, Landi G, Perrone P, Bracchi M and Brambilla G. A randomized trial of aspirin and sulfinpyrazone in patients with TIA. Stroke. 1982;13: ) Fields WS, Lemak NA, Frankowski RF, Hardy RJ: Controlled trial of aspirin in cerebral ischemia. Stroke. 8: ) Bousser MG, Eschwege E, Haguenau M, et al.: “AICLA” controlled trial of aspirin and dipyridamole in secondary prevention of athero-thrombotic cerebral ischemia. Stroke. 14: StudyYearNumber of patients Mean follow- up period Stroke or death risk Canadian Cooperative Study months21% Candelise et al months17% Fields et al months18% Bousser et al months21% In all trials there was a reduction of stroke rates with aspirin therapy. No further placebo trials have been conducted since.

23  NASCET trial sought to compare outcomes of surgery vs. best medical management  659 patients with symptomatic carotid disease  Stroke risk was directly related to degree of stenosis 23 North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med Aug 15;325(7):

24  Stroke risk also correlated to number of risk factors:  Age >70  SBP >160  DBP>90  Recent stroke  Stenosis >80%  Ulcerated plaque  Hx of tobacco use  Diabetes  Claudication  Hyperlipidema 24 North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med Aug 15;325(7): The study was stopped early due to the high stroke rates of medically managed patients. All patients recommended to have CEA

25  659 patients  30 day results  CEA: 5.8%  BMT: 3.3%  2 year results  CEA: 9%  BMT: 26% 25 North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med Aug 15;325(7):

26 Patient with asymptomatic carotid stenosis ≥ 80% (>3 year life expectancy) BMT + Open surgery (CEA) High risk for open surgery? Medical comorbidities Difficult anatomy Best medical therapy (BMT) YES NO 26

27 Patient with symptomatic carotid stenosis ≥ 60% BMT + Endarterectomy High risk for open surgery? Medical comorbidities Difficult anatomy BMT + Stenting YES NO 27

28 28  The natural history of asymptomatic and symptomatic carotid disease is well understood  Asymptomatic patients, there is ongoing debate whether surgical intervention is ever warranted due to improved BMT  Most symptomatic carotid stenosis should undergo intervention


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