Clinical Presentation Clinical Presentation Carotid Artery Carotid Artery Extracranial Carotid Disease Extracranial Carotid Disease Disease Disease • Asymptomatic bruit • Transient ischemic attack (TIA) ( ) • Amaurosis fugax William L Smead, MD • Reversible ischemic neurologic deficit Luther M Keith • Cerebrovascular accident (CVA) Professor of Surgery • Global cerebral ischemia Physical Findings Physical Findings Incidence Of Stroke Incidence Of Stroke Extracranial Carotid Disease Extracranial Carotid Disease • Ranks third as cause of death in USA � 1 of 17 deaths • Cervical bruit • Contralateral motor deficit • 795,000 CVA’s in 2005 • Rate decreased 29.7% • Contralateral sensory deficit � Between 1995 – 2005 • Expressive aphasia/dysarthria • Females > Males • Ocular deficits • Blacks 2x Whites • Global deficit Circulation 2009; 119: 21 1
Pathology Pathology Differential Diagnosis Differential Diagnosis • Extracranial carotid artery disease • Atherosclerosis • Cardiac embolic disease Cardiac embolic disease • Intracranial small vessel disease • Fibromuscular dysplasia • Vasospastic disease (migraine) • Dissection Pathophysiology Pathophysiology Cardiac Sources Cardiac Sources • Paradoxical embolism • Atrial fibrillation • Embolism • Embolism • Atrial myxoma At i l • Valvular disease • Flow reduction • Mural thrombus • Arch disease 2
Arteriography Arteriography Diagnostic Studies Diagnostic Studies • Duplex ultrasonography • EKG / Rhythm strip • Echocardiography • CT Scan / MRI • Arteriography DSA CTA MRA Arteriography Arteriography Medical Therapy Medical Therapy • CT angiography • MR angiography • Risk factor management • Contrast angiography � Tobacco cessation � Hypertension control Attention to aortic arch, extracranial, and � Diabetes management intracranial vessels � Hyperlipidemia treatment Anterior and posterior circulations 3
Statin Therapy Statin Therapy Management of Management of Concomitant Disease Concomitant Disease • Zocor • Lipitor • Crestor • Coronary artery disease • Claudication Target = LDL < 100 • Renovascular disease HDL > 50 • Mesenteric ischemia TG < 150 Major anti-inflammatory effect Antiplatelet Therapy Antiplatelet Therapy Surgical Management Surgical Management • Aspirin • 81 Mg QD • Carotid endarterectomy • 325 Mg QD • Arch reconstruction • Arch reconstruction • Clopidogrel (Plavix) 75 Mg QD • Dypyridamole (A ggrenox ) • Extranatomic bypasses • Ticlopidipine (TICLID) 250 Mg QD • Vertebral revascularization ? Anticoagulation 4
Carotid Endarterectomy Carotid Endarterectomy Carotid Endarterectomy Symptomatic Carotid Endarterectomy Symptomatic Disease 50 – 69% Stenosis Disease 50 – 69% Stenosis Asymptomatic Disease Asymptomatic Disease • Acas study • Nascet study • Randomization: ASA vs CEA Randomization: ASA vs CEA • Randomization: ASA vs CEA R d i ti ASA CEA • Stenosis > 60% • Medical Rx = 11 % @ 5 yrs Medical Rx = 22.2% @ 5 yrs • • CEA Rx = 5.1 % @ 5 yrs CEA Rx = 15.7% @ 5 yrs • JAMA 1995; 273: 1421 NEJM 1998; 339: 1415 Surgery Surgery Carotid Endarterectomy Symptomatic Carotid Endarterectomy Symptomatic Disease 70 – 99% Stenosis Disease 70 – 99% Stenosis Morbidity & Mortality Morbidity & Mortality • Nascet study • Nascet Study 2.1% Death + CVA • Randomization (659 pts): ASA vs CEA ( p ) • Acas Study A St d 1 5% D 1.5% Death + CVA th CVA • Medical Rx = 28% @ 2 yrs Highly selected surgeons CEA Rx = 9% @ 2 yrs • Major medical centers Strict criteria NEJM 1991; 325: 445 5
Carotid Artery Disease Carotid Artery Disease Carotid Endarterectomy Carotid Endarterectomy 20 to 30% of strokes are caused by atherosclerotic carotid artery disease • Carotid artery disease increases the risk for stroke: • By plaque or clot breaking off from the carotid arteries and blocking a smaller artery in the brain • By narrowing of the carotid arteries due to plaque build-up • By a blood clot becoming wedged in a carotid artery narrowed by plaque 1. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for Asymptomatic Carotid Artery Stenosis . JAMA 1995;273:1421 Treatment Modalities Treatment Modalities Endovascular Treatment of Endovascular Treatment of Carotid Artery Disease Carotid Artery Disease • Medical therapy • Carotid endarterectomy Jean Starr, MD, FACS Assistant Professor of Clinical Surgery • Carotid artery stenting Division of Vascular Diseases and Surgery Health System Director of Endovascular Services 6
Medical Treatment Medical Treatment Carotid Endarterectomy Carotid Endarterectomy • Advantages � Good option for those • Disadvantages with short life expectancy (i.e. benefits of � Surgical therapy, longer recovery time endovascular or surgical therapy does not py � Risk of general anesthesia � Risk of general anesthesia outweigh the risks) � Other risks � Does not require hospitalization • Potential for emboli causing stroke • Disadvantages • Cranial nerve palsy � Risk of stroke may be higher • Infection � Risk of hemorrhage � Regular lab monitoring “High Risk” patients for “High Risk” patients for Carotid Endarterectomy Carotid Endarterectomy surgery surgery • Advantages • Contralateral occlusion � Proven history in • Recurrent stenosis after surgery low surgical risk patients low surgical risk patients • History of neck dissection and/or radiation � Safe and effective • “High” lesion (if surgeon and hospital are experienced) • Medically unsuitable patients (class III/IV � Decreases the risk of stroke CHF, unstable angina, recent MI, CABG anticipated, severe COPD) 7
Carotid Artery Stenting Carotid Artery Stenting Carotid Artery Stenting Carotid Artery Stenting • Disadvantages • Treatment � Limited safety/efficacy or long term data – Stenotic artery is opened � Potential for embolization resulting in stroke and plaque “wallpapered” to vessel wall � Currently there are limited experienced clinicians – Endovascular procedure, Endovascular procedure, � Not all patients are suitable for carotid stenting � Not all patients are suitable for carotid stenting femoral access • Severe aortic arch and supra-aortic vessel – Local anesthesia tortuosity and/or calcifications – Embolic protection device • Thrombus deployment • Very long severe lesions – Carotid artery stent • String sign placement • Heavy circumferential calcification Carotid Artery Stenting Carotid Artery Stenting Carotid Artery Stenting Carotid Artery Stenting • Goal of carotid stenting is to reduce • Advantages the risk of future stroke � Treatment option for • Stenting the lesion: patients contraindicated Tapered – Stabilizes and “traps” the plaque for CEA – Reduces the flow pressures on the � Stabilizes the plaque to � St bili th l t plaque Straight minimize risk of – Improves blood flow embolization • Angiographic perfection is not the goal – “The enemy of good is better” � Avoids the risk of cranial nerve damage � Does not require general anesthesia 8
Pre-dilatation of Pre-dilatation of Percutaneous Femoral Percutaneous Femoral Diseased Area Diseased Area Arterial Access Arterial Access • The procedure is completed A balloon catheter may be via the femoral artery under inserted into the stenotic area. local anesthesia with The balloon may be temporarily sedation. A guiding sheath inflated in order to pre-dilate is inserted. Heparin is the artery. administered. 1. Carotid Artery Stenting – A Guide for Patients and Their Families. Guidant Corporation, August 2004. LT 2921888. Embolic Protection Embolic Protection Stent Delivery and Stent Delivery and Deployment Deployment Device Positioning Device Positioning The filter is positioned into • The stent is advanced to the the distal carotid artery. area of the stenosis After area of the stenosis. After After crossing the diseased Aft i th di d careful positioning, the stent area of the artery, the filter will be opened to cover the will be opened. It will stay plaque. in place during the procedure to help capture any plaque or emboli. 1. Carotid Artery Stenting – A Guide for Patients and Their Families. Guidant Corporation, August 2004. LT 2921888. 9
Case Example Case Example Post-Dilatation Post-Dilatation If necessary, a balloon catheter may be re-inserted catheter may be re-inserted into the stent to post-dilate . 1. Carotid Artery Stenting – A Guide for Patients and Their Families. Guidant Corporation, August 2004. LT 2921888. Embolic Protection Embolic Protection System Removal System Removal The stent remains in place. The filter and all other devices will be removed devices will be removed from the body. The filter is re-captured with a retrieval catheter. 1. Carotid Artery Stenting – A Guide for Patients and Their Families. Guidant Corporation, August 2004. LT 2921888. 1. Picture courtesy of Dr. Moreno, Policlínico de Vigo, S.A. (POVISA), Spain 10
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