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Emerging Techniques For Management of Carotid and Brachiocephalic Occlusive Disease for Prevention o

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Extracranial Carotid Artery Disease. CEA in High-Risk Patients ... Symptomatic carotid artery dissection. Methods (continued) ... – PowerPoint PPT presentation

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Title: Emerging Techniques For Management of Carotid and Brachiocephalic Occlusive Disease for Prevention o


1
Emerging Techniques For Management of Carotid and
Brachiocephalic Occlusive Disease for Prevention
of StrokeBrian Whang, Romeo Mateo, Anthony
Pucillo, Jose Botet, Jiyoong Ahn, Hughes,
Albert DeLuca, Arun Goyal, Pravin Shah, Sateesh
BabuNew York Medical College
2
The Problem
3
STROKE
4
Epidemiology
  • Stroke
  • Third leading cause of death in the U.S.
  • 700,000 incident strokes annually
  • 4.4 million stroke survivors
  • 51 Billion cost for 1999
  • Up to 20 due to carotid atherosclerosis
  • Stroke 200132280-299
  • Annals of Neurology 198925382-90

5
Carotid Endarterectomy
  • As of May 29, 2002 the standard of care for the
    treatment of symptomatic and asymptomatic
    cervical carotid artery disease in good risk
    patients remains the carotid endarterectomy (CEA).

6
Extracranial Carotid Artery Disease
7
Extracranial Carotid Artery Disease
8
Extracranial Carotid Artery Disease
9
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10
CEA in High-Risk Patients
  • Cleveland Clinic Experience 1988-1998
  • Stroke, Death, MI rate
  • High Risk (n594) 7.4
  • Low Risk (n2467) 2.9

11
(No Transcript)
12
Minimally Invasive Technology
  • Angioplasty and stenting
  • Proven efficacy and durability
  • Feasible alternative to high-risk surgery
  • Applicable to lesions of the carotid and
    brachiocephalic arteries?

13
Methods
  • 30-month period
  • Multidisciplinary Team Approach
  • Patient Population
  • 74 patients
  • 37 male, 37 female
  • Mean age 66 years old
  • Symptomatic or asymptomatic stenosis
  • High risk for CEA (for ICAS)

14
Methods (continued)
  • Angiographic Indications for Stenting
  • Symptomatic ? 70 stenosis
  • Symptomatic ? 50 contralateral occlusion
  • Asymptomatic ? 80 stenosis
  • Asymptomatic ? 60 contralateral occlusion

15
Methods (continued)
  • High Risk Indications for Stenting
  • Prior CEA with significant restenosis
  • Hostile neck
  • Prior cervical radiation with tissue injury
  • Radical neck dissection or significant
    ipsilateral neck surgery
  • Cervical spine disease or fixation preventing
    extension beyond neutral position

16
Methods (continued)
  • High Risk Indications for Stenting Anatomic
    Difficulty
  • Carotid lesions at the ostium or origin of the
    CCA
  • Lesions higher than C2 or C3 cervical vertebrae
  • Severe tandem ICA and CCA lesions in patients
    with significant co-morbidities
  • Symptomatic carotid artery dissection

17
Methods (continued)
  • High Risk Indications Co-morbid Conditions
    Increasing Risk of CEA
  • Unstable Angina
  • Recent MI / Critical CAD
  • Class III or IV CHF
  • Severe pulmonary disease
  • Uncontrolled DM
  • Bleeding diathesis
  • Contralateral laryngeal nerve palsy

18
Contraindications to Carotid Artery Stenting
  • Severe tortuosity
  • Intraluminal filling defect
  • Occlusion of CCA or ICA
  • Cerebral aneurysm, AVM, or tighter intracranial
    stenosis
  • Major ipsilateral stroke (likely to confound
    study endpoints)
  • Severe neurological illness within the last two
    years

19
ICAS Patient Characteristics (as of 04/02)
Asymptomatic 40 Symptomatic TIA /
Amaurosis 11 CVA 2 VB 0
20
Patient Characteristics(continued)
ICAS High-Risk Category (patients may have more
than one risk factor) Recurrent s/p
CEA 26 Cardiac 20 Respiratory 3 Neck
XRT 7 High Lesion 5 ESRD 4
21
Patient Characteristics (continued)
Total of VESSELS 75 ICA 53 L CCA 1 L
CCA L SCA 2 L SCA 13 Innominate 4
22
Stenting Methods
  • ICAS Technique
  • 1. Wire ECA
  • 2. 6 or 7 Fr Shuttle Sheath to CCA
  • 3. Predilate with 4 x 4 cm coronary balloon
  • 4. 10 x 20 Wallstent or SMART-18 stent
  • 5. Post-dilate with 5 x 2 cm coronary balloon

23
Carotid Artery Stenting
Pre-stent Post-stent
24
Carotid Artery Stenting
Stent
42 year-old woman with a history of cancer
treatment involving neck radiation therapy. She
has been having crescendo TIAs of left arm
weakness.
25
Common Carotid Artery Stenting
Post-stent
Pre-stent
26
Tortuousity Precluding Use of Carotid Stent
27
Brachiocephalic Carotid Stenting Data (as of
04/02)
ICAS Total of Procedures 54 Male 3
2 Female 21 Failed 1 Technical
Success 98 (53/54)
28
Brachiocephalic Carotid Stenting Data (as of
04/02)
BCAS Total of Procedures 20 Male
5 Female 15 Failed 0 Technical
Success 100
29
ICAS Results (as of 04/02)
ICAS Total 54 Technical Success 98
(53/54) Stroke 3.8 (2/53) 1 Expressive
Aphasia 1 Retinal Embolus Deaths 0 Myocard
ial Infarctions 0
30
BCAS Results (as of 04/02)
BCAS Total 20 Technical Success 100 Stro
ke 0 Deaths 0 Myocardial Infarctions 0
31
Outcomes mean everything. Norman Hertzer,
M.D.
  • Stroke/Death Rate
  • CEA in high risk patients 7.4
  • ICAS
  • Lenox Hill- first 99 cases 7.1
  • Worldwide experience first 50 10.1
  • Lenox Hill Case 443-604 4.3
  • Worldwide- Case 300-900 4.1
  • Westchester High Risk ICAS (53 cases) 3.8

32
Carotid Stenting Follow-up Restenosis(as of
04/02)
ICAS cases followed up 53 Duration-mean 17.5
months Degree of restenosis (by duplex)
Cases 0-15 37 16-49 10 50-79
4 80-99 2 Angiographically proven
to be only 40-50 restenosed
33
Recommendations
  • Carotid disease in good-risk patients--gt CEA
  • Carotid disease in good-risk patients--gt CAS only
    in randomized trials
  • High-risk patients --gt CEA with cervical block or
    intensive monitoring
  • Higher-risk patients --gt CAS only under strict
    protocols or randomized trials

34
Conclusions
  • Endovascular treatment of carotid and
    brachiocephalic occlusive disease is a viable
    option for the treatment of patients at high risk
    for standard operative repair.
  • A multidisciplinary approach and rigid patient
    selection are critical for success.
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