Title: Emerging Techniques For Management of Carotid and Brachiocephalic Occlusive Disease for Prevention o
1Emerging 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
2The Problem
3STROKE
4Epidemiology
- 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
5Carotid 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).
6Extracranial Carotid Artery Disease
7Extracranial Carotid Artery Disease
8Extracranial Carotid Artery Disease
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10CEA in High-Risk Patients
- Cleveland Clinic Experience 1988-1998
- Stroke, Death, MI rate
- High Risk (n594) 7.4
-
- Low Risk (n2467) 2.9
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12Minimally Invasive Technology
- Angioplasty and stenting
- Proven efficacy and durability
- Feasible alternative to high-risk surgery
- Applicable to lesions of the carotid and
brachiocephalic arteries?
13Methods
- 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)
14Methods (continued)
- Angiographic Indications for Stenting
- Symptomatic ? 70 stenosis
- Symptomatic ? 50 contralateral occlusion
- Asymptomatic ? 80 stenosis
- Asymptomatic ? 60 contralateral occlusion
15Methods (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
16Methods (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
17Methods (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
-
18Contraindications 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
19ICAS Patient Characteristics (as of 04/02)
Asymptomatic 40 Symptomatic TIA /
Amaurosis 11 CVA 2 VB 0
20Patient 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
21Patient Characteristics (continued)
Total of VESSELS 75 ICA 53 L CCA 1 L
CCA L SCA 2 L SCA 13 Innominate 4
22Stenting 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
23Carotid Artery Stenting
Pre-stent Post-stent
24Carotid 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.
25Common Carotid Artery Stenting
Post-stent
Pre-stent
26Tortuousity Precluding Use of Carotid Stent
27Brachiocephalic Carotid Stenting Data (as of
04/02)
ICAS Total of Procedures 54 Male 3
2 Female 21 Failed 1 Technical
Success 98 (53/54)
28Brachiocephalic Carotid Stenting Data (as of
04/02)
BCAS Total of Procedures 20 Male
5 Female 15 Failed 0 Technical
Success 100
29ICAS 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
30BCAS Results (as of 04/02)
BCAS Total 20 Technical Success 100 Stro
ke 0 Deaths 0 Myocardial Infarctions 0
31Outcomes 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
32Carotid 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
33Recommendations
- 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
34Conclusions
- 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.