Disclosures Minor Stroke Effects Long-Term None Survival after - PowerPoint PPT Presentation

4/4/2014 Disclosures Minor Stroke Effects Long-Term • None Survival after CAS/CEA Joseph H. Rapp, MD Chief, Vascular Surgery Service SFVAMC Professor of Surgery, UCSF Late Mortality post Peri-procedural MI CREST DATA (CREST) • Combined end point of Stroke, Death and MI 1 yr 4 yr equivalent – � Stroke with CAS, � MI with CEA 42 MI’s 6 (14.3%) 8 (19.1%) • Published F/U article showing, as predicted, decreased survival after peri-procedural MI 20 non-STEMI 1 (5.0%) 4 (25%) • Over 4 yrs: 3.4 fold increase mortality after MI 2440 No MI 44 (2.2%) 111 (6.7%) (EKG); 3.7 fold increase mortality post procedure Bio Marker rise Blackshear Circ 2011 1

4/4/2014 Stroke Definition Late Mortality post Stroke (CREST) I can tell if a patient has had a peri-procedural Stroke. A. Yes. When there is a change, the patient 90% knows, the family knows, I know. B. No. C. Maybe, but it is often quite subtle 10% 0% . . o . . . . . e N h t i t t n u b e h , W e b y . a s M e Y Late Mortality post Peri-procedural Stroke Definition 2 Stroke (CREST) There are NIH consensus guidelines on what • 300 “potential” events constitutes a Major and a Minor Stroke. • 46 deemed TIA or amaurosis fugax A. Yes. They are commonly used to grade • 81 adjudicated as stroke 65% deficits after stroke (Fischer, Stroke 2010) • 69 were peri-procedural B. No. The Neurologist can’t agree on – 56 Minor anything 22% – 13 Major 13% C. Not sure. . . . Hill Circ 2012 . . . e e . r r o u a r s u y e t e N o N h T e h . T s e Y o . N 2

4/4/2014 Late Mortality post peri-procedural Late Mortality post Stroke (CREST) Stroke or MI (VSGNE) 1yr 5 yr 1 yr 4 yr 81 16% 44% Stroke (any) 17% 21.2% MI’s (69) 63 23% 40% P<0.001 No Stroke 3% 11.6% Strokes (2272) 8171 4% 20% Neither Blackshear Circ 2012 Simons JVS 2013 Late Mortality post Peri-procedural Survival post TIA (Dutch) Stroke or TIA (Bologna) 5 yr Stroke 68.2% 29 TIA 78.4% 38 No Event 97% 1323 Wijk Lancet 2005 Pini JVS 2014 3

4/4/2014 Why is Stroke a marker for poor Late Outcomes after Carotid survival? Intervention • Peri-procedural MI is bad and Stoke is worse • Minor Stroke and even TIA substantially reduce long term survival • Unknown role for silent ischemia (DW-MRI) • A new era where we recognize that peri- procedural outcomes are only part of the cost of intervention. Brain uniquely susceptible to emboli 4

4/4/2014 CREST showed a poor long-term What is a “Minor” Stroke? outcome for peri-op MI Late Mortality post Peri-procedural Stroke or TIA (Bologna) 5 yr 29 Strokes 68.2% 38 TIA’s 78.4% 1323 Neither 97% 5