Chapter 92 - Carotid artery stenting Flashcards
(47 cards)
first proposal of carotid angioplasty
Mathias 1977
First proposal of CAS
1987 Marks
stroke rate 6-9%
First use of cerebral protection devices
1990 Theron
Key RCT comparing CAS and CEA
1) SAPPHIRE
2) EVA-3S
3) SPACE
4) ICSS
5) CREST
6) ACT-1
SAPPHIRE (US)
Stenting and angioplasty with protection in patients at high risk for endarterectomy
1) 2004, 2008
2) 334 patients
3) > 50% symptomatic or > 80% asymptomatic
4) EPD use 97%
5) primary: composite death, stroke, MI 30 days or ipsi stroke 1 year
6) 1 year 12.2% vs 20.1%; 3 eyar 24.6 vs 26.9% CAS vs CEA
7) non-inferior, not superior
EVA 3S (FRENCH)
Endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis
1) 2006, 2008
2) 527 patients
3) > 60% symptomatic only
4) EPD 92%
5) primary: any stroke/death 30 days
6) 30 day: 9.6 vs 3.9%; 6 months 11.7 vs 6.1%; 4 year 11.1 vs 6.2%
7) CAS worse stroke/death
trial stopped early
much worse if no EPD used
criticism: not trained IR people
SPACE trial (GERMAN)
Stent-supported percutaneous angioplasty of the carotid artery versus endarterectomy
1) 2006, 2008
2) 1200 patients
3) > 70% symptomatic
4) EPD 27%
5) primary: ipsi stroke death 30 days
6) 30d 6.8 vs 6.3%; 2 year 9.5 vs 8.8%
7) higher risk periprocedural with CAS
stopped early due to cost
fail to show non-inferiority
higher rate of restenosis
ICSS (UK)
International carotid stenting study
1) 2010, 2015
2) 1713 patients
3) > 50% symptomatic
4) EPD 72%
5) primary: 3 year fatal or disabling any stroke
6) 120 days 8.5 vs 5.2%; 4.2 year 6.4 vs 6.5%
7) long term risk of disabling stroke similar
CREST (US)
Carotid revascularization endarterectomy versus stenting trial
1) 2010, 2016
2) 2502 patients
3) carotid stenosis > 70% on ultrasound or symptomatic > 50% on angio
4) EPD 96%
5) composite stroke, MI, death 30 days or ipsilateral stroke 4 years
6) 4 year 7.2 vs 6.8%; 10 year 11.8 vs 9.9%
7) no sig long term difference between the two in composite endpoint or risk of stroke
risk of stroke/death higher in symptomatic patients getting CAS
6 vs 3.2%
ACT-1 (US)
Carotid angioplasty and stenting versus endarterectomy in asymptomatic subjects who are at standard risk for carotid endarterectomy with significant extracranial carotid stenotic disease
1) 2016
2) 1453 patients
3) > 80% asymptomatic carotid stenosis
4) EPD 100%
5) primary: composite death, stroke, MI, 30 day or ipsi stroke 1 year
6) 30d: 2.9 vs 1.7%; 1 year 3.8 vs 3.4%
7) CAS not inferior
ACA/AHA recommendation for symptomatic carotid stenosis with CAS
1) CAS is alternative if average risk, > 70% imaging or > 50% DSA
2) CAS in > 70% stenosis with high risk comorbidity or neck hostility
3) periprocedural morbidity/mortality < 6%
SVS on CAS in symptomatic disease
1) CAS in > 50% stenosis and hostile neck/previous nerve injury or beyond clavicle-C2 lesion
2) > 50% stenosis and uncorrectable CAD, CHF, COPD
ESC guideline on CAS in symptomatic disease
1) CAS alternative if high surgical risk
2) death/stroke rate < 6% by operating site
ACC/AHA on asymptomatic CAS
1) >60% angio or > 70% doppler
2) not clear if better than BMT
SVS on asymptomatic CAS
1) 70-99% stenosis
2) CAS only if stroke/death < 3% at the centre
ECS on asymptomatic CAS
1) > 60%
2) < 3% death/stroke rate
Center for medicare and medicaid service on CAS
1) symptomatic > 70% if high risk for CEA
2) symptomatic 50-70% if enrolled in trial
3) asymptomatic > 80% if enrolled in trial
Definition of patients high risk for CEA
1) CHF class 3-4
2) LVEF < 30
3) unstable angina
4) contralateral carotid occlusion
5) recent MI
6) previous CEA
7) previous radiation
Evidence on CAS with age
SPACE post-hoc
ipsi stroke death 2.7% < 68 yo
10.8% > 68 yo
CEA similar
CREST post-hoc
composite outcome increase 1.77x per 10 yr increment
overall higher risk when > 70 years old
evidence on CAS with sex
CREST showed women did worse with stroke in CAS
other trials did not
higher debris size captured in EPD for women
? symptomatic women higher risk for CAS?
Absolute contraindication to CAS
1) visible thrombus in carotid lesion
2) active infection
3) inability to gain vascular access
Relative contraindication to CAS
1) older age
2) circumferential carotid plaque with calcification
3) severe tortuosity with 2x 90 degree angles
4) near occlusion (string sign)
5) inability to deploy protection device
3 types of aortic arch morphology
TYPE 1: great vessels arise at or above the horizontal place as the outer curvature of arch
TYPE 2: origin of innominate between horizontal plane of inner and outer curve
TYPE 3: innominate lies below horizontal plane of inner curvature
Stroke rate increase in CAS if ICA-CCA angulation > 60 degrees
4.96 x
