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R9 > Chapter 92 - Carotid artery stenting > Flashcards

Chapter 92 - Carotid artery stenting Flashcards

1
Q

first proposal of carotid angioplasty

A

Mathias 1977

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2
Q

First proposal of CAS

A

1987 Marks

stroke rate 6-9%

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3
Q

First use of cerebral protection devices

A

1990 Theron

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4
Q

Key RCT comparing CAS and CEA

A

1) SAPPHIRE
2) EVA-3S
3) SPACE
4) ICSS
5) CREST
6) ACT-1

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5
Q

SAPPHIRE (US)

Stenting and angioplasty with protection in patients at high risk for endarterectomy

A

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

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6
Q

EVA 3S (FRENCH)

Endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis

A

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

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7
Q

SPACE trial (GERMAN)

Stent-supported percutaneous angioplasty of the carotid artery versus endarterectomy

A

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

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8
Q

ICSS (UK)

International carotid stenting study

A

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

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9
Q

CREST (US)

Carotid revascularization endarterectomy versus stenting trial

A

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%

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10
Q

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

A

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

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11
Q

ACA/AHA recommendation for symptomatic carotid stenosis with CAS

A

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%

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12
Q

SVS on CAS in symptomatic disease

A

1) CAS in > 50% stenosis and hostile neck/previous nerve injury or beyond clavicle-C2 lesion
2) > 50% stenosis and uncorrectable CAD, CHF, COPD

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13
Q

ESC guideline on CAS in symptomatic disease

A

1) CAS alternative if high surgical risk

2) death/stroke rate < 6% by operating site

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14
Q

ACC/AHA on asymptomatic CAS

A

1) >60% angio or > 70% doppler

2) not clear if better than BMT

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15
Q

SVS on asymptomatic CAS

A

1) 70-99% stenosis

2) CAS only if stroke/death < 3% at the centre

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16
Q

ECS on asymptomatic CAS

A

1) > 60%

2) < 3% death/stroke rate

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17
Q

Center for medicare and medicaid service on CAS

A

1) symptomatic > 70% if high risk for CEA
2) symptomatic 50-70% if enrolled in trial
3) asymptomatic > 80% if enrolled in trial

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18
Q

Definition of patients high risk for CEA

A

1) CHF class 3-4
2) LVEF < 30
3) unstable angina
4) contralateral carotid occlusion
5) recent MI
6) previous CEA
7) previous radiation

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19
Q

Evidence on CAS with age

A

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

20
Q

evidence on CAS with sex

A

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?

21
Q

Absolute contraindication to CAS

A

1) visible thrombus in carotid lesion
2) active infection
3) inability to gain vascular access

22
Q

Relative contraindication to CAS

A

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

23
Q

3 types of aortic arch morphology

A

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

24
Q

Stroke rate increase in CAS if ICA-CCA angulation > 60 degrees

A

4.96 x

25
Q

Plaque length on risk of CAS stroke

A

EVA-3S trial: > 10 mm causes 2.36x risk of stroke

CREST: > 12.85 mm causes 3.42x risk of stroke

26
Q

timing of CAS after event

A

EVA-3S, SPACE, ICSS pooled analysis: highest risk of CAS in first 7 days

Carotid acculink/accunet post-approval trial to uncover unanticipated or rare events (CAPTURE) registry - worse outcome of CAS in 0-13 days
CAS done in first 4 weeks 6% vs > 4 weeks 8% composite outcome similar

inconclusive on timing but maybe not right away

27
Q

ROADSTER trial

A

Test ENROUTE neuroprotective system using transcarotid artery revascularization TCAR

1) 208 patients
2) symp > 50% or asymp > 70%
3) stroke 1.4%

28
Q

Steps in TFCAS

A

1) 6F 90cm sheath in descending aorta
2) catheter cannulate CCA
3) 035 wire into mid CCA
4) catheter advance to just below bifurcation
5) sheath advanced as well
6) 014 buddy wire in ECA may help maintain platform in position
7) angiogram and EPD
8) Predilation 2.5-4 mm coronary balloon to 4-6 atm maybe necessary
9) deliver stent
10) retrieval of EPD and angiogram
11) maybe nitroglycerin 100-200 mcg

29
Q

Types of embolic protection devices

A

1) Filter-type EPD
- uninterrupted cerebral blood flow
- low number of manipulations in carotid vessel
- have to traverse carotid lesion for deployment

2) distal occlusion balloon (Theron et al)
- balloon occlude antegrade flow in distal ICA
- needs removal after suctioning out debris
- still has to traverse lesion

3) proximal protection EPD
- Mo.Ma: occlusive balloon in CCA and ECA
- suction dry before deflating
- ENROUTE TCAR: flow reversal with filter
- prevent need for crossing lesion
- larger sheath needed

30
Q

Percentage of patients that cannot tolerate flow reversal

A

5-9%

31
Q

Types of carotid stents - material

A

1) stainless steel (cobalt alloy)

2) nitinol (nickel-titanium): higher radial force

32
Q

Types of carotid stents - struts

A

1) open cell: more conformable/flexible

2) close cell: better scaffolding of vessel wall

33
Q

Sizing of carotid stents

A

to the largest portion of artery = distal CCA

34
Q

Effect of post-dilation

A
  1. 1x increase hemodynamic depression
  2. 4x increase in stroke/death

reserved for severe residual stenosis

35
Q

Treatment of post angioplasty hypotension

A

Atropine iv 0.4-1mg

phenylephrine 1-10 mcg/kg
dopamine 5-15 mcg/kg/min

36
Q

Risk for persistent hypotension post-CAS

A

1) lesion from bifurcation to max stenosis < 1cm
2) eccentric stenosis
3) echogenic plaque morphology
4) calcified carotid bifurcation

37
Q

Antiplatelet therapy in CAS

A

DAPT 4 days prior and for 30days minimum post

Ticlopidine 250 BID can replace plavix

38
Q

Anticoagulation in CAS

A

no indication

RCT showed worse effect that was terminated early

39
Q

statin in CAS

A

CV events lower with statin 4 vs 15%

stroke and death 1.5 vs 4%

40
Q

Technical complications of CAS

A

1) stent thrombosis - convert to CEA
2) kinking - observe if mild
3) carotid dissection - additional stent

41
Q

neurological complication of CAS

A

1) embolism - embolic retrieval, tpa, aspiration, glycoprotein IIb/IIIa receptor inhibitor
2) intracranial hemorrhage
3) hyperperfusion

42
Q

Microembolic events in CAS subclinical rate

A

71% vs 4% CEA

43
Q

Rate of stent fracture in CAS

A

9% 0-37 months after surgery

44
Q

Carotid and vertebral artery transluminal angioplasty study CAVATAS on 10 year restenosis rate

A

30.7% compared to 11% CEA

26% if just stent not POBA

45
Q

CREST on restenosis of CAS

A

6% vs 6.3% CEA more comparable

46
Q

Risk of CAS restenosis factors

A

1) longer lesion > 0.65 of CCA diameter
2) DM
3) female
4) dyslipidemia

47
Q

Ongoing trials on CAS

A

1) SPACE-2: BMT vs intervention and CAS vs CEA
- primary outcome: stroke/death 30d and stroke ipsi 5yr

2) ACST-2: CAS vs CEA in asymptomatic
- 30d MI/stroke/death; 5yr stroke

3) ECST2: BMT vs CAS/CEA with > 50% stenosis
- asymp or symp
- primary any stroke/death 30d

4) CREST2: BMT vs revasc asymp > 70%
- BMT vs CAS
- BMT vs CEA
- primary stroke/death 44d; ipsi stroke 4 yr

5) ROADSTER2: TCAR study
- primary 30d procedure
- stenosis > 50% symp or > 80% asymp

R9 (200 decks)

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