Carotid Stenting Current Indications 24 August 2016 Christopher Bajzer
Conflict of Interest None
Carotid Atherosclerosis Why Intervene? Annual risk of having a stroke is a function of degree of stenosis In a person WITHOUT symptoms annual risk of having a stroke is not as high as you may think Medical therapy reduces risk of stroke in patients with carotid disease Stop smoking Control BP Control Lipids Control DM Single antiplatelet agent = aspirin 81 mg
Annual Stroke Risk in an Asymptomatic Patient as a Function of Carotid Stenosis Severity 4 3.5 3 2.5 2 1.5 CVA%/yr 1 0.5 0 0-19% 20-39% 40-59% 60-79% 80-99% 100% N ENGL J MED 2000; 342:1693-1701
Carotid Disease Asymptomatic Carotid Stenosis Facts 7-10% men & 5-7% women over age 65 have carotid stenosis > 50% There is a 1-2% risk of stroke per year with a hemodynamically significant (> 60%) carotid stenosis 4 published Randomized Controlled Trials addressed the benefit of CEA in asymptomatic carotid stenosis 2 Randomized Controlled Trials address clinical equivalence of CS with EPD with CEA Circulation 2001: 103: 163-182. NEJM 2008: 358: 1572-79. NEJM 2010: 363: 11-23
Carotid Symptoms Possibly Carotid Related Weakness arm and/or same side leg (opposite side carotid) Inability to speak or understand the written or spoken word (opposite side carotid of dominant hand) Loss of vision in an eye like a window shade coming down (same side carotid) Not Carotid Related Weak, tired/fatigue, dizzy or syncope Neck pain or other pain Memory loss, forgetful Symptoms mapped to both sides of brain or opposite side of brain to the diseased carotid
Why Carotid Stent? Reduce risk of stroke or TIA equal to surgery Stenting is often Patient driven Less invasive (cosmetic?) Faster return to normal living No risk associated with anesthesia No risk of surgical complications Infection, nerve injury: voice, swallow In US trials - Clinical equivalence with CEA
2004 CMS Approves Carotid Stent Option Patient s covered under CMS Symptomatic; 70% carotid stenosis; in a patient at high risk for CEA. Must use FDA approved carotid stent and emboli protection Currently represents 10% of stents performed at Cleveland Clinic
US Insurance Coverage Carotid Stents & EPDs CMS guidelines apply to patients covered under CMS policies this is a subset of US population Private insurance usually follow CMS lead but: ALLOW for pre-authorization for coverage depending on policy written and case-by-case basis for patients that do not fall under current CMS guidelines Pre-authorization is largest stent group at Clinic
Who is Symptomatic? (according to CMS) Amaurosis Fugax causally related to high grade carotid disease TIA defined as focal neurologic deficit persisting < 24 hours causally related to high grade carotid disease Focal ischemia resulting in a NON-disabling Stroke (modified RANKIN < 3) EXCLUDE Disabling Stroke (modified RANKIN 3 = moderate disability or worse) 20-45% Symptomatic patients in setting of high grade carotid disease are UNRELATED to carotid disease
Who is High Surgical Risk? (according to CMS) CHF NYHA FC III-IV LV EF 30% USAP CC III-IV Contra-lateral carotid occlusion MI within 6 weeks Re-stenosis post CEA Radiation treatment to neck
More High Surgical Risk Other inclusion criteria in SAPPHIRE, ARCHeR, BEACH, CABERNET, MAVERIC II trials Age > 80 years ESRD on HD Severe Pulmonary Dz Inaccessible lesion Tracheostomy Abnormal Stress Test Need for CABG Contra-lateral n. palsy
Who gets to stent? 5724 hospitals total in US (AHA) 1311 (23%) hospitals have federal institutional approval to perform carotid stenting Average about 2 operators/approved (0-10) hospital meet some societal criteria (Radiology, Vascular Surgery, Cardiology, Vascular Medicine) to be credentialed to stent carotid artery at an institution with federal carotid stent approval
Carotid Stent Trials Take Home Points Confirmations EPD use cuts risk more than 50% Operator skill impacts outcomes Clinical Equivalence with CEA in US trials Restenosis data replicated repeatedly at 1% per year or less advantage over CEA Risk highest in ESRD on HD and age > 80 years
Carotid Stenting Who Gets Deferred? If possible, wait 2-4 weeks after a stroke before performing carotid intervention Document pre-existing deficits! Patients requiring CABG must wait 2-4 weeks after carotid intervention before surgery - Be sure they can wait! A - DW MRI B CT R MCA CVA Stroke 30: 2059, 1999
Carotid Stenting Who Gets Turned Down? Patients with significant dementia should not have carotid intervention. Asymptomatic patients must have life expectancy greater than 2 years! Thrombus in the carotid String (closed) carotid Static CCF patient
Example Carotid Stent
Example Carotid Stent
Example Carotid Stent
Carotid Disease What to do after revascularization? In Hospital: Neurologic checks every 4 hours Control BP (SBP 90-140 / DBP 50-80) Pressure on carotid body causes low BP IVF first line Liquid Sudafed 15-30 mg q4h second line Low dose dopamine if symptomatic or recalcitrant SBP above 140 can cause brain edema or bleed Vitals with neurologic checks and treat any elevated BP New baseline carotid duplex
Carotid Disease What to do after revascularization? Back home and seeing you in follow-up: Aspirin 81 mg daily for Life Plavix 75 mg daily for 4-6 weeks NO smoking High intensity statin per guidelines Control BP per guidelines Control DM per guidelines Duplex carotid ultrasound ANNUALLY
Bajzer