2. Selecting Patients Best Suited for CEA
Nick Hopkins MD
Mandy Binning MD
Elad Levy MD
Adnan Siddiqui MD, PhD
Dept of Neurosurgery
SUNY Buffalo

3. L. Nelson Hopkins, MD DISCLOSURES Consulting Fees
Abbott Vascular, Bard Peripheral Vascular, Boston Scientific Corporation, Micrus Endovascular Cordis, a Johnson & Johnson company
Grants/Contracted Research
Cordis, a Johnson & Johnson company, Boston Scientific Corporation, Micrus Endovascular
Honoraria
AccessClosure, Inc., Bard Peripheral Vascular, Boston Scientific Corporation, Cordis, a Johnson & Johnson company, marketRx, Inc., Micrus Endovascular, Medsn
Ownership Interest (Stocks, Stock Options or Other Ownership Interest)
APW Holding, Inc., Boston Scientific Corporation, Magellan Spine Tech, Inc., MedFocus Accelerator Fund, Micrus Endovascular

4. Carotid Endarterectomy
The most studied
operation in
the world

5. CEA
CEA is effective in reducing risk of stroke in carefully selected patients with symptomatic carotid stenosis ≥ 50% or asymptomatic carotid stenosis ≥ 70%
Many variations on CEA technique are in use, but none have been proven to be superior
Certain subgroups are at higher risk of complications with CEA

6. Symptomatic Carotid Stenosis
NASCET
70-99% stenosis: 17% (26 to 9%)ARR (65% RRR) / 2 yrs
50-69% stenosis: 6.5% ARR (29% RRR) / 5 yrs
<50% stenosis: no benefit
Favors CEA for 50-99% symptomatic stenosis
13.1% vs. 2.5% with CEA for major ipsilat. CVA
ECST (reanalysis by NASCET criteria, Lancet 2003;34:514)
3,024 pts w/ TIA, retinal infarction, or non-disabling stroke within 6 months
70-99% stenosis: 21.2% ARR / 5 yrs
50-69% stenosis: 5.7% ARR / 5 yrs
<50% stenosis: no benefit (harm if <30% stenosis)

7. Outcome after CEA depends on risk for perioperative complications
NASCET: 30-day rate of disabling stroke and death was 2.9%
ECST 30-day rates
disabling stroke: 2.5%
death: 1.0%

8. Asymptomatic RCT’s: Best Med Tx ± CEA
ACAS (JAMA 1995;273:1421)
1,662 pts w/ angio or validated doppler > 60%
5.9% ARR (53% RRR) / 5 yrs
required low surgical M&M (1.5%)
no stat. sig. benefit for women
ACST (Lancet 2004;363:1491)
3120pts w/ doppler > 60% stenosis
5.4% ARR (11.8→6.4% risk) / 5 yrs
results more robust than ACAS
surgical M&M (3.0%)

9. AHA Recommendations
CEA in symptomatic patients should be undertaken by surgeons whose surgical morbidity and mortality rate is <6%
Moore et al., Stroke 26: , 1995

10. High-Risk features for CEA
Anatomical
C2 and higher lesion
Contralateral carotid occlusion / stenosis (is relative)
Severe ulceration
Tandem intracranial stenosis
Functional
Age > 80 (some say 75)
Active coronary artery disease (before intervention)
Recent major stroke in reference vascular territory

11. AHA Recommendations
CEA in asymptomatic patients should be undertaken by surgeons whose surgical morbidity and mortality rate is <3%
Moore et al., Stroke 26: , 1995

12. Patient Evaluation
CEA is most effective when patients are selected appropriately
NASCET, ECST, VACS: patient eligibility was based on angiographic criteria
Furthermore, CEA in asymptomatic patients carries a narrow risk-benefit ratio, making accurate patient selection essential

13. Carotid Duplex Ultrasonography: Limitations
Significant proportion of CEAs are performed in centers without designated, accredited vascular labs
Goldstein Stroke 26: , 1995
Even accredited, high-volume vascular labs may report false-positive results for carotid stenosis in 20-41% of cases
Qureshi Stroke 32: , 2001
Duplex scanning cannot accurately distinguish preocclusive disease from total occlusion
Dawson J Vasc Surg 18: , 1993
Duplex scanning does not indicate whether the lesion is relatively high in the cervical region, which is information that is important for surgical planning
Duplex scanning does not image the intracranial vasculature

14. Radiographic Evaluation
Doppler alone is NOT enough
MRA or CTA + Doppler ok if congruent
Angio still gold standard for anatomy and collateral circulation

15. Degree of Stenosis – Asymptomatic Stenosis
ACAS: No effect of degree of stenosis on risk of stroke or perioperative risk
Stroke 20: 844–849, 1989
NASCET: Risk of stroke ipsilateral to asymptomatic side did correlate with stenosis
Barnett et al., Neurology 46:603–608, 1996
Figure: Barnett et al., Neurology 46:603–608, 1996

16. Multicenter Review of Preoperative Risk Factors for CEA in Patients with Symptomatic Stenosis
1,160 CEAs performed at 12 academic medical centers
697 patients with ipsilateral symptoms
8.5% had either stroke, MI, or died during the postoperative period of hospitalization.
Those >75 yo had a greater risk of MI (6.6% vs 2.3%, P=.024) but not of stroke or death (P>.10)
Variables with >90% probability of being associated with adverse outcomes
age ≥75 years
angiographic evidence of
ipsilateral carotid occlusion
stenosis in the region of the carotid siphon
intraluminal thrombus
Goldstein et al., Stroke 25: , 1994

17. Endarterectomy in the Elderly
11,973 CEAs
No significant difference in stroke rate in patients aged < or > 75 yo
Mortality 2.14% in >75 yo vs 0.88% in <75 yo (P =.0001)
Maxwell et al., Am J Surg 1997;174:

18. Heart Disease
Patients with coronary artery disease are also at an elevated risk of perioperative stroke and death, with an incidence as high as 40%
Ferguson et al., Stroke 24: , 1993

19. Subgroup Analysis: Ulcerated Plaque
NASCET: Risk of perioperative stroke or death was 1.5 times higher in the presence of an ipsilateral ulcerated plaque
Ferguson et al., Stroke 30: , 1999

20. Intracranial Stenosis
ACAS: Presence of contralateral carotid siphon stenosis was associated with a significantly higher risk of perioperative stroke after CEA
Young et al. Stroke 27: , 1996

21. Contralateral Occlusion
NASCET: Perioperative risk of stroke and death is increased in the presence of contralateral carotid occlusion (14.3% vs. 4.0%)
Gasecki et al. J Neurosurg 83: , 1995

22. Absence of Collateral Circulation
NASCET: Risk of perioperative stroke in patients with an absence of collaterals on angiography is increased by a factor of 4 (4.9% vs. 1.1%)
Henderson et al. Stroke 31: , 2000

23. Intraluminal Thrombus
NASCET: 30-day stroke risk for CEA in patients with an intraluminal thrombus was 12.0%
Villareal et al., Stroke 29:276, 1998

24. CAS Risk Factors CEA a Better Alternative than CAS + Filter
Sx (hot) lesion…
Elderly pts… ??
Low GSM…
Multiple stents…
Duration Filter…
Pre dil without EP …
Tortuousity- severe…
Concentric calcium…
Aortic Arch disease…
Renal Failure...

25. Conclusions CEA: a good operation
CEA: great alternative for most high risk CAS pts
Acceptable risk: 3% Asx and 6% Sx
CEA Risk factors/pts to avoid CEA
Body habitus, high & low lesions
Medical comorbitities: cardiac, resp
Hostile neck
Severe intracranial ds/poor collateral circulation
Neurologic instability

26. Thank you