1. Vascular D&C M. Uchiyama02/01/2013

2. Introduction  Complication  R MCA distribution embolic stroke  Procedure  R carotid angiography with planned, but aborted R carotid stent, carotid endarterectomy  Primary Diagnosis  Asymptomatic R carotid 70-79% re-stenosis 13 yrs s/p carotid endarterectomy

3. Clinical History HPI: 73 yr old female s/p bilateral CEA’s & re-stenosis of R common & internal carotid 13 yrs postop  PMHx: CAD, HLD, OSA requiring CPAP, TIA, DM, cutaneous lupus, depression, fibromyalgia  PSHx: R CEA (1999, Chippenham), L CEA (2008, VCU), CABGx3 (2008, VCU)  Relevant Meds: ASA, plavix & pravastatin (continued through perioperative period)  Social: Lives with husband, no history of smoking/EtOH/drug use

4. Preoperative History  Seen 4/2012 in neurology clinic with multiple episodes of headache, presyncope & syncope MRI Head/Neck: Bilateral vertebral & basilar artery stenosis High grade common and moderate internal carotid artery stenosis Posterior communicating arteries not visualized R carotid dissection could not be excluded  Carotid duplex 12/11/12: R ICA 70-79% stenosis RCCA50-80% stenosis L ICA 50-59% stenosis L CCA <50% stenosis

5. Perioperative/Operative Period  Patient seen in vascular clinic 12/18/12 and was sent to ED with hypertensive urgency (systolic 214, headache)  Re-evaluated 1/8/12, non-focal neurologic examination documented & plans made for carotid stenting  OR 1/11/2012: Carotid angiography converted to carotid endarterectomy

6. Vascular Surgery M&M Conference VCUHS  1/31/2013  Ayo Akinrinlola, MD PGY 7

7. Procedural Steps of CAS – Access – Aortic Arch Angiogram – Selective Common Carotid Cannulation – Crossing the Internal Carotid Stenosis – Predilatation – Stent Delivery – Postdilatation – Retrieval of the Cerebral Protection Device and Completion Angiography – Access Hemostasis

8. – Access – Aortic Arch Angiogram – Selective Common Carotid Cannulation – Crossing the Internal Carotid Stenosis – Predilatation – Stent Delivery – Postdilatation – Retrieval of the Cerebral Protection Device and Completion Angiography – Access Hemostasis Procedural Steps of CAS

19. Rescue techniques during CAS Mechanical removal of an embolus Aspiration of an embolus/thrombus Fragmentation techniques Intra-arterial thrombolysis

20. Immediate Postoperative Period  Patient extubated, transferred to STICU  Patient sleepy, but arousable, no facial droop and LUE/LLE motor intact but weaker than RUE/RLE  Imaging ordered  CT Head, CTA head/neck  MRI head

21. Imaging  CT Head, CTA head/neck  Evolving infarction of R parietal and temporal lobe in posterior R MCA distribution  Dissection of mid R common carotid with 50% reduction of true lumen  Abrupt cutoff M2 Branch of R MCA resembling acute thrombus  Hypoplastic R vertebral artery

23. MRA Head  Posterior division R MCA infarction including posterior R frontal lobe and most of R temporal lobe  Separate areas consistent with embolic infarction of R frontal lobe and posterior R frontal lobe

25. Outcome  Due to increasing somnolence, patient was intubated pod#0  Hypertension requiring nipride drip & NSTEMI pod#3  Remains intubated pod#20 due to slowly resolving angioedema of tongue likely related to ACE inhibitor (lisinopril)  Can move RUE/RLE, withdraws to pain LUE/LLE  Tracheostomy/PEG 1/30/12  Plans for long term rehab

26. Analysis of Complication Was the complication potentially avoidable? – Possibly Would avoiding the complication change the outcome for the patient? – Yes What factors contributed the complication? – Embolization after manipulation of wires in carotid artery from dissection site or friable existing plaque – Inability to complete cerebral angiogram during endovascular procedure

27. CREST Trial “Carotid Revascularization Versus Stenting Trial” Stroke, 2010

28. Before CREST  NASCET Trial (1995):  2,226 patients with symptomatic stenosis randomized to either medical management or endarterectomy  Endarterectomy was superior to medical management & decreased stroke rate 65% in patients with 70% stenosis, to a lesser extent in those with 50-69% stenosis and there was no difference with <50% stenosis

29. Before CREST  ACAS Trial (1995):  1,662 patients without symptoms & with 60% stenosis were randomized to either medical management or endarterectomy  Endarterectomy was superior to medical management in patients with stenosis >60%

30. CREST Trial  Largest randomized prospective study comparing CEA to carotid artery stenting  CEA and stenting were shown to be equivalent in 30 day composite outcomes of stroke, MI or death  Stenting had higher rates of periop stroke, but that majority of these were nonmajor  CEA was associated with higher periop MI  CEA and stenting were shown to be equivalent in 4 year outcomes of stroke

31. CREST Trial  2,522 Symptomatic & asymptomatic patients were included  Inclusion criteria: Symptomatic (TIA, amaurosis, ipsilateral minor stroke) with >70% stenosis by US or asymptomatic with >70% stenosis by US with favorable anatomy for both procedures  Exclusion criteria: evolving stroke, h/o major stroke, atrial fibrillation on anticoagulation, MI within 30 days, unstable angina

32. CREST Trial  1,271 were assigned to stenting and 1,251 were assigned to CEA  Only statistically significant difference between groups was higher incidence of dyslipidemia in CEA group  Endpoints: Stroke (either perioperatively or up to 4 years postop), MI, death

33. CREST Trial Outcomes: Perioperative  Stroke, MI, Death (Combined): 5.2% (stenting) v. 4.5% (CEA) HR 1.18, 95% CI 0.82–1.68, P =.38  Major ipsilateral stroke: 0.9% vs 0.3% HR 2.67, 95% CI 0.85–8.40, P =.09  MI: 1.1% vs 2.3% R 0.50, 95% CI 0.26–0.94, P =.03  Cranial nerve palsy: 0.3% vs 4.8% HR 0.07, 95% CI 0.02–0.18, P <.0001

34. CREST Trial Outcomes at Four Years  Stroke, MI, death, or ipsilateral stroke: 7.2% (stenting ) v. 6.8% (CEA) HR 1.11, 95% CI 0.81–1.51  Ipsilateral stroke: 2.0% v. 2.4%, HR 0.94, 95% CI 0.50–1.76, P =.85

35. CREST Trial Findings  Risk of ipsilateral periprocedural minor stroke higher with stenting, although risk of long-term stroke was nearly equal (2.0 v. 2.4%)  MI slightly more likely in CEA group  Patients over 70 yrs did better with CEA, while younger patients did better with stenting  Compared to previous studies, rate of stroke and composite outcomes after CEA was lower  Embolic protection devices were used in 96.1% of stenting cases  Participating surgeons were more experienced with low documented complication rates  Improved medical therapy  Less wound complications in stenting group

36. CREST Trial Limitations  Study design altered midway to include asymptomatic patients  Lesion length, calcification and lesion location were not accounted for  Study design only included experienced operators