Carotid Artery Disease Management
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1 Carotid Artery Disease Management Adam J. Doyle, MD, RPVI Assistant Professor of Surgery Medical Director Vascular Surgery Ultrasound Laboratory University of Rochester Medical Center Department of Surgery Division of Vascular Surgery
2 Financial Disclosures None Conflicts of Interest None
3 Carotid Artery Disease Management Learning Objectives: -Understand the role of carotid artery disease in stroke -Understand the role of ultrasound in the diagnosis of Carotid stenosis -Understand the basics of best medical therapy for the treatment of carotid artery stenosis. - Understand when surgery for carotid artery stenosis is indicated.
4 Introduction: - Stroke 3 rd leading cause of death in the USA - More than half a million new strokes each - The leading cause of serious long-term disability - Direct and indirect costs at $40 billion
5 Causes of Stroke
6 Carotid Artery Anatomy 1) cervical, 2) ascending petrous, 3) horizontal petrous, 4) ascending cavernous, 5) horizontal cavernous, 6) clinoid, 7) ophthalmic, and 8) terminal
7 Carotid Artery Stenosis Pathology
8 Carotid Artery Stenosis Epidemiology
9
10 Contributing metabolic factors to stroke risk
11 Increasing risk of stroke with progressive carotid artery stenosis
12 Carotid Artery Stenosis Diagnosis
13 Carotid Artery Stenosis Screening Carotid Ultrasound: - Considered for asymptomatic patients who have - PAD - CAD - AAA - At least two risk factors for stroke including: - high blood pressure - high cholesterol - tobacco smoking - a first-degree relative with atherosclerosis that developed before age 60 - a family history of ischemic stroke
14 STRANDNESS CRITERIA ZWIEBEL CRITERIA Stenosis, % Characteristics Stenosis, % Characteristics Normal PSV < 125 cm/sec 0 PSV < 110 cm/sec No SB EDV < 40 cm/sec Flow reversal in bulb PSV ICA/CCA < 1.8 EDV ICA/CCA < 2.4 SB < 30 cm/sec 1-15 PSV < 125 cm/sec 1-39 PSV < 110 cm/sec No or minimal SB EDV < 40 cm/sec Flow reversal in bulb absent PSV ICA/CCA < 1.8 EDV ICA/CCA < 2.4 SB < 40 cm/sec PSV > 125 cm/sec PSV < 130 cm/sec Marked SB EDV < 40 cm/sec PSV ICA/CCA < 1.8 EDV ICA/CCA < 2.4 SB < 40 cm/sec PSV > 125 cm/sec PSV > 130 cm/sec EDV < 140 cm/sec EDV > 40 cm/sec PSV ICA/CCA > 1.8 EDV ICA/CCA > 2.4 SB > 40 cm/sec PSV > 125 cm/sec PSV > 250 cm/sec EDV > 140 cm/sec EDV > 100 cm/sec PSV ICA/CCA > 3.7 EDV ICA/CCA > 5.5 SB > 80 cm/sec
15 Carotid Artery Stenosis Medical Management for all patients with carotid stenosis - Medical regimen including: - Statin therapy mg/day aspirin -Antihypertensive medications -Risk factor modification including: - Smoking cessation -Routine Surveillance Ultrasound once stenosis is identified
16 Carotid Artery Stenosis Medical Management Statin therapy (conclusions based upon results of numerous RTC s): -All patients with carotid artery stenosis should be treated with statin medications as tolerated (multiple RCT s) -Each 10% reduction in LDL cholesterol was estimated to reduce the risk of stroke by 15.6%. (Paraskevas KI, Hamilton G, Mikhailidis DP. Statins: an essential component in the management of carotid artery disease. J Vasc Surg 2007;46:
17 Carotid Artery Stenosis Medical Management Antiplatelet therapy (Aspirin): -Has been shown to reduce incidence of stroke by 25% (Antithrombotic Trialists Collaboration. Collaborative meta-analysis of randomised trials of anti-platelet therapy for prevention of death, myocardial infarction and stroke in high risk patients. BMJ 2002;324: ) -Meta-analysis of 21 trials supports the us of aspirin of 75 mg- 150 mg per day (Antithrombotic Trialists Collaboration. Collaborative meta-analysis of randomised trials of anti-platelet therapy for prevention of death, myocardial infarction and stroke in high risk patients. BMJ 2002;324: ) - Plavix can be used in patients who cannot take Aspirin. -No evidence to support DAPT
18 Carotid Artery Stenosis Medical Management Anticoagulation: -Offers no greater benefit than aspirin but did have a significantly increased risk of causing intracranial hemorrhage. (Berge E, Sandercock P. Anticoagulants versus antiplatelet agents for acute ischaemic stroke. Cochrane Database Syst Rev 2002;(4): CD )
19 Carotid Artery Stenosis Medical Management Blood pressure control: -Control of blood pressure can lead to a 30% to 40% reduction in stroke and is one of the most modifiable risk factors for carotid artery disease (Sillesen H. What does best medical therapy really mean? Eur J Vas Endovasc Surg 2008;35: ) -The use of low dose thiazides (bendrofluazide) and ACE inhibitors (captopril, ramipril) decrease stroke risk (Wright JM, Musini VM. First-line drugs for hypertension. Cochrane Database Syst Rev 2009;(3):CD , Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin converting enzyme inhibitor, Ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000;342: , Hanson L, Lindholm L, Niskanen L, Lanke J, Hedner T, Niklason A, et al. Effect of angiotensin-converting-enzyme inhibition compared with conventional therapy on cardiovascular morbidity and mortality in hypertension: the Captopril Prevention Project (CAPP) randomised trial. Lancet 1999;353:611-6.)
20 Carotid Artery Stenosis Surgical Management (CEA) Asymptomatic Carotid Artery Stenosis: - Several trials comparing CEA to BMT with long term f/u - Several trials to compare CEA to CAS - Ongoing trials comparing CEA, CAS, and BMT Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis Stroke. 2015;46:
21 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial Prof Alison Halliday, FRCS, Prof Michael Harrison, FRCP, Elizabeth Hayter, BMus, Xiangling Kong, MSc, Prof Averil Mansfield, FRCS, Joanna Marro, MSc, Hongchao Pan, PhD, Prof Richard Peto, FRS, Prof John Potter, FRCP, Kazem Rahimi, DM, Angela Rau, MBBS, Steven Robertson, BA, Jonathan Streifler, MD, Prof Dafydd Thomas, FRCP The Lancet Volume 376, Issue 9746, Pages (September 2010) DOI: /S (10)61197-X Copyright 2010 Elsevier Ltd Terms and Conditions
22 Figure 3 The Lancet , DOI: ( /S (10)61197-X) Copyright 2010 Elsevier Ltd Terms and Conditions
23 Asymptomatic Carotid Stenosis Brott TG, et al. Stenting versus Endarterectomy for Treatment of Carotid artery stenosis. N Engl J Med ;363:11-23.
24 Carotid Artery Stenosis Surgical Management (CEA) Asymptomatic Carotid Artery Stenosis: - Greater than 80% stenosis - Good functional/cognitive status - Life expectancy > 5 years - <1 percent surgical risk (physiological) - Surgeon with < 1 percent stroke risk - Absence of ESRD Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis Stroke. 2015;46:
25 Carotid Artery Stenosis Surgical Management (CEA) Symptomatic Carotid Artery Stenosis: - CEA for patients with 50-79% stenosis and symptoms while on BMT or lesions deemed high risk for stroke (symptoms while not on BMT) at average to moderate risk for surgery (physiological or anatomic). - CEA for patients with >80% stenosis and symptoms at average to moderate risk for surgery (physiological or anatomic) Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis Stroke. 2015;46:
26 Asymptomatic Carotid Stenosis Brott TG, et al. Stenting versus Endarterectomy for Treatment of Carotid artery stenosis. N Engl J Med ;363:11-23.
27 Carotid Artery Stenosis Surgical Management (CAS) Symptomatic Carotid Artery Stenosis: - CAS for patients with 50-99% stenosis and symptoms while on BMT at prohibitive risk for CEA Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis Stroke. 2015;46:
28 Carotid Artery Disease Management Conclusions: -Carotid artery stenosis is a significant cause of preventable stroke -Diagnosed and surveillance is performed by duplex ultrasound -Screen ultrasound should be performed on all patients with risk factors for carotid disease -Medical therapy has a large role in prevention of stroke related to carotid artery stenosis -CEA is indicated for low risk asymptomatic patients with >80% stenosis and low-moderate risk patients with 50-99% symptomatic stenosis -CAS is rarely indicated Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis Stroke. 2015;46:
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