3. Un homme de 67 ans connu pour HTA et dyslipidémie
sous traitement avec ASA, hydrochlorothiazide et
Simvastatin présente un souffle carotidien gauche.
Au questionnaire le patient est asymptomatique. Au
Doppler on démontre une sténose de 70-80%
Quel est votre approche?
1)Traitement médical
2)Endartérectomie carotidienne
3)Angioplastie carotidienne avec tuteur
9. • « Scientists tend to work within one set of ideas about
how the world is. Everything they do, be it
experimental or theoretical, is informed by, and
framed within, that set of ideas. However, there will
be evidence that does not fit. At first, that evidence
will be ignored or sabotaged. Eventually though, the
anomalies will pile up so high that they simply cannot
be ignored or sabotaged any longer. Then comes
crisis »
-Thomas Kuhn
10. Arguments déjà entendus:
•S’il s’agissait de maladie cardiaque
•Recommandation de AHA sont basées sur les plus grandes évidences
•50% de réduction d’AVC si opéré
•Les complications péri-opératoires sont en diminution
•Politiquement incorrecte de refuser la chirurgie aux femmes
•Mais le patient lui , il retient quoi?
•80% des AVC n’ont pas de Sx prémonitoire
•Les patients ne sont pas compliants à leur médication
•Mettons l’emphase sur l’individu et non la population
11. Arguments à entendre:
•Les bénéfices exposés par ACAS/ACST sont minimes
•Peu de consensus et l’AHA recommande l’endartérectomie chez les patients
hautement sélectionnés sans autre définition
•La vaste majorité des patients subissant une réparation n’étaient jamais destinés
à souffrir d’un AVC
•La vaste majorité des patients subiront une intervention non nécessaire,
mobilisant beaucoup de ressources inutilement
•Traitement médical a changé l’histoire naturel de la maladie asymptomatique
•La population à risque demeure à être définie
12. CASANOVA
206 pts - 334endarterectomies
End points:AVC, Mortalité à 3 ans
Résulats: Médical: 10,7%
Chirurgie: 11,3% p=0,486
Limitation: Beaucoup de cross-over
ICT non considérés échec
Randomisation complexe
13. MACE
• Publiée en 1992
• Seulement 71 patients
• Pas d’analyse valable car trop peu d’événement neurologique
• Étude terminée car trop de complications cardiaques et ICT dans
le groupe chirurgical
• Absence d’ASA
Carotid Revascularization for Prevention of Stroke: Carotid
Endarterectomy and Carotid Artery Stenting
Thomas G. Brott, MD, Robert D. Brown Jr, MD, MPH, Fredric B. Meyer, MD, David A. Miller, MD, Harry J.
Cloft, MD, PHD, Timothy M. Sullivan, MD
14. VA-Asymptomatic
444 hommes avec sténose de >50%
End points: AVC et Mortalité
Durée: 1983-1991; suivi moyen 4 ans
Traitement médical: ASA 325mg bid
Exclusion: EV <5 ans, haut risque chirurgical
18. ACAS
• 1662 patients Décembre 1987 et décembre 1993
• Hommes et femmes 40-79 ans
• Artério ou doppler >60%; tous ont eu artério
• Traitement médical: ASA 325mg
• Endpoints: Changement en cours d’étude
– Initial: Tout ICT/AVC Ispi ou tout ICT/AVC périop ou mortalité
– Ensuite: Seulement AVC Ispi ou tout AVC périop ou mortalité
20. • Suivi médian 2,7 ans
• Extrapolation des résultats à 5 ans
• Diminution du risque absolu: 5,9% (1% par année)
• Diminution du risque relatif: 53%
• Morbidité neuro/mortalité opératoire: 2,3% (2,7% incluant angio)
• Bénéfice plus grand chez homme que femme (66% vs 17%; NS)
• Complications périopératoires homme 1,7%; Femme 3,7% (NS)
• Pas de bénéfice en lien avec degré de sténose
• Tendance à bénéfice chez patients plus jeunes mais non significatif
21. • Exclusion de 40% des chirurgiens
• Pas de puissance pour les sous-groupes
• Changement de protocole en cours d’étude
• Traitement médical variable(seulement ASA)
• Résultats extrapolés à 5 ans
• Exclusion >80 ans, MCAS récent ou EV diminuée
• Risque périopératoire bas comparativement au résultats de population
22. ACST-5 ans
• 3120 hommes et femme de avril 1993- juillet 2003
• Doppler ou artério: Sténose >60%
• Exclusion des patients à haut risque
• Endpoints: Morbidité neuro et mortalité périopératoire
Incidence d’événement neurologique
24. ACST-5 ans
• Suivie moyen 3.4 ans – résultats à 5 ans
• Risque périopératoire 3,1% (AVC ou mortalité)
• Réduction absolu de 5,4% et relatif de 50%
• Bénéfice chez femmes seulement si risque périopératoire exclu
• Pas de relation avec degré de sténose
• Pas de bénéfice si >75 ans
• Augmentation des statines durant étude
27. Évidence
should possibly stop intervening altogether
in asymptomatic patients.15,16
ACAS3
and ACST4,5
failed to resolve the
debate about the treatment of asympto-
published, the largest single increase in the
number of CEA procedures in the US state
of Florida (93% increase) was in patients aged
>84 years.17
Second, concerns were expressed
Table 1| Outcomes from ACAS and ACST
Trial n Operative
risk (%)
Risk of
stroke
with
BMT (%)
Risk of
stroke with
CEA* (%)
ARR
with
CEA (%)
RRR
with
CEA (%)
NNT
with
CEA
Strokes
prevented per
1,000 CEAs
5-year outcomes
ACAS3
1,662 2.3 11.0 5.1 5.9 54 17 59
ACST4
3,120 2.8 11.8 6.4 5.4 46 19 53
10-year outcomes
ACST5
3,120 2.8 17.9 13.4 4.6 26 22 46
*The 5-year and 10-year CEA data include the 30-day risk of death or stroke. Abbreviations: ACAS, Asymptomatic Carotid
Atherosclerosis Study; ACST, Asymptomatic Carotid Surgery Trial; ARR, absolute risk reduction in stroke; BMT, best medical
therapy; CEA, carotid endarterectomy; NNT, number needed to treat to prevent one stroke; RRR, relative risk reduction in stroke.
P E R S P E C T I V E S
should possibly stop intervening altogether
in asymptomatic patients.15,16
ACAS3
and ACST4,5
failed to resolve the
debate about the treatment of asympto-
published, the largest single increase in the
number of CEA procedures in the US state
of Florida (93%increase) was in patients aged
>84 years.17
Second, concerns were expressed
Table 1| Outcomes from ACAS and ACST
Trial n Operative
risk (%)
Risk of
stroke
with
BMT (%)
Risk of
stroke with
CEA* (%)
ARR
with
CEA (%)
RRR
with
CEA (%)
NNT
with
CEA
Strokes
prevented per
1,000 CEAs
5-year outcomes
ACAS3
1,662 2.3 11.0 5.1 5.9 54 17 59
ACST4
3,120 2.8 11.8 6.4 5.4 46 19 53
10-year outcomes
ACST5
3,120 2.8 17.9 13.4 4.6 26 22 46
*The 5-year and 10-year CEA data include the 30-day risk of death or stroke. Abbreviations: ACAS, Asymptomatic Carotid
Atherosclerosis Study; ACST, Asymptomatic Carotid Surgery Trial; ARR, absolute risk reduction in stroke; BMT, best medical
therapy; CEA, carotid endarterectomy; NNT, number needed to treat to prevent one stroke; RRR, relative risk reduction in stroke.
P E R S P E C T I V E S
29. Quel est le problème?
SYMPTOMATIQUE
•Accepté interdisciplinaire
•Différence considérable
•Analyse de sous groupe
ASYMPTOMATIQUE
•Discordance interdisciplinaire
•Différence mineure
•Peu d’analyse de sous-groupe
30. Considérations historiques
Années Faits
1991 40% des chirurgiens applicants rejetés
1995 Avec un risque de 2,3%, CEA prévient 59 AVC/1000 sur 5 ans
Incluant le risque chx, CEA confère pas de bénéfice au femmes (ACAS)
Pas de lien entre degré de sténoses et risque AVC (ACAS)
1997 Canadian Stroke Consortium ne recommande pas CEA et dépistage
2000 CEA ne confère pas de bénéfice chez occlusion contralatéral (ACAS)
55% des AVC retardé sont d’origine cardioembolique (ACAS)
2001 Risque périopératoire >3% dans 7 États sur 10 (moyenne 5,9%)
2002 Si ACAS avait été analysé à 4 ans: Pas de bénéfice ( NASCET investigators)
2003 Europena Stroke Initiative: Tx médical est probablement meilleur
2004 Pas de bénéfice chez > 75 ans (ACST)
Pas d’association entre sévérité et bénéfice (ACST)
Si risque chx inclus: Pas d’avantage chez la femmes (ACST)
Risque chirurgical 5,4% dans 10 États basés sur critère d’ACST
Méta-analyse démontre mortalité 8 fois plus grande que ACAS
Méta-analyse démontre AVCMortalité 3 fois plus grande que ACAS
31. Considérations historiques
Années Faits
2005 92% des CEA au USA sont Asymptomatiques
2007 US Preventive Service Task force ne recommande pas dépistage
2008 Le risque d’AVC annuel est en déclin depuis 20 ans
2009 Revvue systmatique démontre que Tx médical est plus sécuritaire
2010 Statine à haute dose diminue les risque d’AVC
ACST-10ans démontre RRA de 4,6% (0,46%par année)
2011 Évaluation post-CREST démontre que l’évidence d’intervenir est faible et que
CAS ne devrait pas être offert avant d’autre données
33. Manque de Consensus
Although surgery reduces the incidence of ipsilateral stroke, the absolute
benefit of carotid surgery is small, as the rate of stroke in medically treated
patients is low [Benavente et al., 1998]. Medical management alone is the best
alternative for many asymptomatic subjects.
35. Manque de Consensus
A 67-year-old man with a history of hypertension and hyperlipidemia is seen for a routine
examination. His medications include hydrochlorothiazide (25 mg daily), simvastatin (20 mg daily),
and aspirin (81 mg daily). Auscultation of the neck shows normal carotid upstrokes but reveals a
middle-pitched bruit only in systole at the angle of the right jaw. A detailed neurologic examination is
normal.
On questioning, the patient does not report any history of transient neurologic deficits — specifi-
cally, no unilateral weakness or sensory symp- toms, visual disturbances, or speech or language
difficulty.
Noninvasive testing of the carotid arteries re- veals a stenosis of 70 to 80% of the proximal right,
38. Manque de Concensus
… evidence for any invasive treatment of asymptomatic carotid disease is weak, with recent
data favouring purely medical management
…more contemporary data are needed on the medical management of asymptomatic carotid
disease before either CAS or CEA can be recommended…
…there is a danger that CREST will be interpreted as sanctioning treatment of asymptomatic
disease, which is not warranted by the available data.
39. Sous-groupes?
• Femmes
– Bien reconnu dans NASCET
– ACAS: Pas de bénéfice pour les femme meme si risque
périopératoire exclu
– ACTS: Bénéfice seulement si risque opératoire exclu
• Age >75 ans
– ACAS: Pas de données suffisante (Inclusion <80ans)
– ACST: Pas d’avantage au >75 ans
40. Sous-groupes?
• Degré de sténose
– ACST: Bénéfice seulement si risque périprocédure est exclue
– ACAS: Pas de bénéfice même si risque périprocédure exclu
– Pas de bénéfice lorsque données combinées
• Sténose contralatérale
– Bien reconnu dans NASCET
– ACAS: - Peu de patient
- Patient pas plus à risque
41. Intervention de masse
• But Ultime: Prévention d’événement
should possibly stop intervening altogether
15,16
published, the largest single increase in the
Table 1| Outcomes from ACAS and ACST
Trial n Operative
risk (%)
Risk of
stroke
with
BMT (%)
Risk of
stroke with
CEA* (%)
ARR
with
CEA (%)
RRR
with
CEA (%)
NNT
with
CEA
Strokes
prevented per
1,000 CEAs
5-year outcomes
ACAS3
1,662 2.3 11.0 5.1 5.9 54 17 59
ACST4
3,120 2.8 11.8 6.4 5.4 46 19 53
10-year outcomes
ACST5
3,120 2.8 17.9 13.4 4.6 26 22 46
*The 5-year and 10-year CEA data include the 30-day risk of death or stroke. Abbreviations: ACAS, Asymptomatic Carotid
Atherosclerosis Study; ACST, Asymptomatic Carotid Surgery Trial; ARR, absolute risk reduction in stroke; BMT, best medical
therapy; CEA, carotid endarterectomy; NNT, number needed to treat to prevent one stroke; RRR, relative risk reduction in stroke.
P E R S P E C T I V E S
should possibly stop intervening altogether
15,16
published, the largest single increase in the
Table 1| Outcomes from ACAS and ACST
Trial n Operative
risk (%)
Risk of
stroke
with
BMT (%)
Risk of
stroke with
CEA* (%)
ARR
with
CEA (%)
RRR
with
CEA (%)
NNT
with
CEA
Strokes
prevented per
1,000 CEAs
5-year outcomes
ACAS3
1,662 2.3 11.0 5.1 5.9 54 17 59
ACST4
3,120 2.8 11.8 6.4 5.4 46 19 53
10-year outcomes
ACST5
3,120 2.8 17.9 13.4 4.6 26 22 46
*The 5-year and 10-year CEA data include the 30-day risk of death or stroke. Abbreviations: ACAS, Asymptomatic Carotid
Atherosclerosis Study; ACST, Asymptomatic Carotid Surgery Trial; ARR, absolute risk reduction in stroke; BMT, best medical
therapy; CEA, carotid endarterectomy; NNT, number needed to treat to prevent one stroke; RRR, relative risk reduction in stroke.
P E R S P E C T I V E S
90%
80%
42. Intervention de masse
• Calcul efficacité – Pour 100 AVC…
– 100 - 20 d’origine hémoragique = 80
– 80 – 20 d’origine vertébrobasilaire = 60
– 60 x 50% d’origine carotidienne = 30
– 30 – 20 (23 Sténose < 60%) = 10
– 10 x 80% d’AVC franc = 8
– 8 x 50% (ACAS) = 4
44. Allocation des ressources
• Prévalence de sténose 60-99% est de 1%
• Donc 10 000 par millions d’habitants
• Si 4 chirurgies par jours pour 260 jours travaillés
• 9,6 ans de temps opératoire
45. Traitement médical
• Utilisation des statines à haute dose
– SPARCL: Diminution de 16% du risque d’AVC sur 5 ans
• Contrôle tensionnel plus aggressif
– Utilisation des IECA (HOPE et PROGRESS)
• Utilisation des antiplaquettaires en prévention primaire
• Modification du style de vie
– Alimentation, tabagisme et exercice physique
• Cessation de l’hormonothérapie chez la femme
46. Traitement médical
Third,neitherACASnorACSTshowed
thatincreasingseverityofstenosiswasan
5 years,and918(92%)ofprocedureswould
stillbeunnecessary.36
Table3| Temporal changes in the 5-year stroke risk* in ACAS and ACST
Trial Yearsoffollow-up Year published Any stroke(% pa) Ipsilateral stroke (% pa)
ACAS3
1–5 1995 17.5 (3.5) 11.0 (2.2)
ACST4
1–5 2004 11.8 (2.4) 5.3 (1.1)
ACST5,37
6–10 2009 7.2 (1.4) 3.6 (0.7)
*In medically treated patients. Abbreviation: pa,per annum.
P E R S P E C TIV E S
Third,neitherACASnorACSTshowed
thatincreasingseverity ofstenosiswasan
5 years,and918(92%)ofprocedureswould
stillbeunnecessary.36
Table3| Temporal changes in the 5-year stroke risk* in ACAS and ACST
Trial Yearsoffollow-up Yearpublished Anystroke (% pa) Ipsilateral stroke (%pa)
ACAS3
1–5 1995 17.5 (3.5) 11.0 (2.2)
ACST4
1–5 2004 11.8 (2.4) 5.3 (1.1)
ACST5,37
6–10 2009 7.2 (1.4) 3.6 (0.7)
*In medically treated patients. Abbreviation: pa,per annum.
P E R S P E C TIV E S
47. Traitement médical
rereportedin
skhasdimin-
many of the
ompromised.
a systematic
of stroke had
hat noninter-
ly safer than
8 times more
strokeriskhas
rovements in
dicaltherapy,
statintherapy
ar disease. A
wn that high-
symptomatic
1984
0
1989
1
2
3
4
5
6
Any stroke; 50–99% stenosis
Any stroke; 50–99% stenosisAny stroke; 60–99% stenosis
Any stroke; 70–99% stenosis
Ipsilateral stroke; 50–99% stenosis
Ipsilateral stroke; 60–99% stenosis
Ipsilateral stroke; 70–99% stenosis
58
Year
Annualratesofstroke(%)
1994 1999 2004 2009
63
59
62
44
45
68
68
44
66
66
63
64
60
60
67
77
55
77
ACAS3
ACAS3 ACST 1–5 years4
61
54
54
ACST 6–10 years5
ACST 6–10 years5
ACST 1–5 years4
61
65
69
ACAS ‘any stroke’
ACAS ‘ipsilateral stroke’
P E R S P E C T IV E S
rereportedin
skhasdimin-
many of the
ompromised.
a systematic
f stroke had
at noninter-
ly safer than
8 times more
trokeriskhas
rovements in
dicaltherapy,
statintherapy
ar disease. A
n that high-
symptomatic
1984
0
1989
1
2
3
4
5
6
Any stroke; 50–99% stenosis
Any stroke; 50–99% stenosisAny stroke; 60–99% stenosis
Any stroke; 70–99% stenosis
Ipsilateral stroke; 50–99% stenosis
Ipsilateral stroke; 60–99% stenosis
Ipsilateral stroke; 70–99% stenosis
58
Year
Annualratesofstroke(%)
1994 1999 2004 2009
63
59
62
44
45
68
68
44
66
66
63
64
60
60
67
77
55
77
ACAS3
ACAS3 ACST 1–5 years4
61
54
54
ACST 6–10 years5
ACST 6–10 years5
ACST 1–5 years4
61
65
69
ACAS ‘any stroke’
ACAS ‘ipsilateral stroke’
P E R S P E C T IV E S
50. Donc…
• Pas de concensus
• Intervention de masse ne prévient que 4% de AVC
• 96% des procédures sont inutiles
• Mauvais allocation des ressources
– 2 billions de USD par année
• Lignes directrices de l’AHA
– « CEA or CAS on highly selected patients»
• Mais qui sont ces patients…
51.
52. À Risque…degré de sténose
Severity of Asymptomatic Carotid Stenosis and Risk of
Ipsilateral Hemispheric Ischaemic Events: Results from the
ACSRS Study
A.N. Nicolaides,1 , 4
* S.K. Kakkos,1
M. Griffin,1
M. Sabetai,1
S. Dhanjil,1
T. Tegos,1
D.J. Thomas,2
A. Giannoukas,1
G. Geroulakos,1 , 3
N. Georgiou,4
S. Francis,1
E. Ioannidou,4
C.J. Dore´5
and For the Asymptomatic Carotid Stenosis and Risk of
Stroke (ACSRS) Study Group
Departments of 1
Vascular Surgery, Imperial College, 2
Neurology, St Mary’s Hospital, 3
Vascular Surgery,
Ealing Hospital, London, UK; 4
TheCyprus Instituteof Neurology and Genetics, Nicosia, Cyprus; and 5
MRC
Clinical Trials Unit, London, UK
Objectives. This study determines the risk of ipsilateral ischaemic neurological events in relation to the degree of
asymptomatic carotid stenosis and other risk factors.
Methods. Patients (nZ 1115) with asymptomatic internal carotid artery (ICA) stenosis greater than 50% in relation tothe
bulbdiameter werefollowed up for aperiod of 6–84 (mean 37.1) months. Stenosiswasgraded using duplex, and clinical and
biochemical risk factors wererecorded.
Results. Therelationship between ICA stenosisand event rateislinear when stenosisisexpressed by theECST method, but
S-shaped if expressed by the NASCET method. In addition to the ECST grade of stenosis (RR 1.6; 95% CI 1.21–2.15),
history of contralateral TIAs(RR 3.0; 95% CI 1.90–4.73) and creatininein excessof 85 mmol/L (RR 2.1; 95% CI 1.23–3.65)
wereindependent risk predictors. Thecombination of these three risk factors can identify a high-risk group (7.3% annual
event rateand 4.3% annual strokerate) and a low risk group (2.3% annual event rate and 0.7% annual stroke rate).
Conclusions. Linearity between ECST per cent stenosis and risk makes this method for grading stenosis moreamenableto
risk prediction without any transformation not only in clinical practice but also when multivariable analysis is to beused.
Identification of additional risk factors provides a new approach to risk stratification and should help refinetheindications
for carotid endarterectomy.
Keywords: Asymptomatic; Carotid; Stenosis; Risk; NASCET; ECST.
Introduction
Thedegree of internal carotid artery (ICA) stenosis is a
(ACAS).2
It hasbecome known astheNorth American,
‘NASCET’ or ‘N’ method.3
The second method
expresses the residual lumen as a percentage of the
Eur JVasc Endovasc Surg 30, 275–284 (2005)
doi:10.1016/ j.ejvs.2005.04.031, available online at http:/ / www.sciencedirect.com on
–1115 patients
–Sténose de plus de 50% à l’échographie
–Suivi moyen 37 mois
Severity of Asymptomatic Ca
Ipsilateral Hemispheric Ischaem
Eur JVasc Endovasc Surg 30, 275–284 (2005)
doi:10.1016/ j.ejvs.2005.04.031, available online at http:/ / www.scienced
53. À Risque…degré de sténose
Severity of Asymptomatic Carotid Stenosis and Risk of
Ipsilateral Hemispheric Ischaemic Events: Results from the
ACSRS Study
A.N. Nicolaides,1 , 4
* S.K. Kakkos,1
M. Griffin,1
M. Sabetai,1
S. Dhanjil,1
T. Tegos,1
D.J. Thomas,2
A. Giannoukas,1
G. Geroulakos,1 , 3
N. Georgiou,4
S. Francis,1
E. Ioannidou,4
C.J. Dore´5
and For the Asymptomatic Carotid Stenosis and Risk of
Stroke (ACSRS) Study Group
Departments of 1
Vascular Surgery, Imperial College, 2
Neurology, St Mary’s Hospital, 3
Vascular Surgery,
Ealing Hospital, London, UK; 4
TheCyprus Instituteof Neurology and Genetics, Nicosia, Cyprus; and 5
MRC
Clinical Trials Unit, London, UK
Objectives. This study determines the risk of ipsilateral ischaemic neurological events in relation to the degree of
asymptomatic carotid stenosis and other risk factors.
Methods. Patients (nZ 1115) with asymptomatic internal carotid artery (ICA) stenosis greater than 50% in relation tothe
bulbdiameter werefollowed up for aperiod of 6–84 (mean 37.1) months. Stenosiswasgraded using duplex, and clinical and
biochemical risk factors wererecorded.
Results. Therelationship between ICA stenosisand event rateislinear when stenosisisexpressed by theECST method, but
S-shaped if expressed by the NASCET method. In addition to the ECST grade of stenosis (RR 1.6; 95% CI 1.21–2.15),
history of contralateral TIAs(RR 3.0; 95% CI 1.90–4.73) and creatininein excessof 85 mmol/L (RR 2.1; 95% CI 1.23–3.65)
wereindependent risk predictors. Thecombination of thesethreerisk factors can identify a high-risk group (7.3% annual
event rate and 4.3% annual strokerate) and a low risk group (2.3% annual event rateand 0.7% annual stroke rate).
Conclusions. Linearity between ECST per cent stenosis and risk makes this method for grading stenosis moreamenableto
risk prediction without any transformation not only in clinical practicebut also when multivariable analysis is to beused.
Identification of additional risk factors provides a new approach to risk stratification and should help refinetheindications
for carotid endarterectomy.
Keywords: Asymptomatic; Carotid; Stenosis; Risk; NASCET; ECST.
Introduction (ACAS).2
It has become known astheNorth American,
3
Eur JVasc Endovasc Surg 30, 275–284 (2005)
doi:10.1016/ j.ejvs.2005.04.031, available online at http:/ / www.sciencedirect.com on
56. À Risque…Aspects cliniques
• Genre
– Femmes avait plus de complications préopératoires dans ACAS
• Age
– < 75 ans semblent avec le plus grand bénéfice
– Idéalement survie >5 ans
• ATCD d’évènement contralatéral
– ACSRS: 3,4% vs 1,2%
p<0.0001
57. À Risque…Radiologique
Morphologie de la plaque à l’Échographie
– Gray-Scale median
• Mesure de valeur de gris des pixel de la plaque en entier
• Bas: Plaque peu échogène
• Haut: Plaque plus échogène
• Plus les valeur sont basse, plus la plaque est à risque
– Aire de la plaque
• Plus l’aire est grande plus de risque de symptômes
– Aire noire juxta-luminale
• Représente des zones plus molles de la plaque
• Proportionnel aux symptômes
58. À Risque…Radiologique
Infarctus silencieux
– Que veux dire symptomatique lorsque nous dormons 1/3 du
temps?
– Tout ICT survenant durant cette période passe inaperçu et les
patients sont toujours « cliniquement asymptomatique »
– Que ces patients asymptomatiques avec évidence radiologique au
TDM d’infarctus silencieux sont à plus haut risque demeure un
toujours un débats
59. À Risque…RadiologiqueTable III. Distribution of contralateral embolic infarction and other infarct typ
infarction on computed tomography scanning
Type
Ipsilateral embolic infarction, No. (%)
Present (n 146) Absent (n 675)
Other infarct types, ipsilaterally 21 (14.4) 3 (0.4)
Contralateral embolic infarction 81 (55.5) 91 (13.5)
Other infarct types, contralaterally 17 (11.6) 8 (1.2)
CI, Confidence interval; OR, odds ratio.
a
These included watershed and basal ganglia lacunesin the ipsilateral or contralateral hemisphere.
906 Kakkoset al
60. À Risque…Radiologique
Détection d’embolie à l’échographie
•Doppler transcranien
Table 5| Studies* correlating baseline embolization with late risk of ipsilateral stroke54
Study Ipsilateral strokes
in patients with
embolic signals
Ipsilateral strokes
in patients without
embolic signals
OR (95% CI)
ACES54
5/77 (6.5%) 5/390 (1.3%) 5.35 (1.51–18.94)
Abbott et al.77
2/60 (3.3%) 4/171 (2.3%) 1.44 (0.26–8.07)
Molloy & Markus78
1/12 (8.3%) 0/30 (0%) 7.96 (0.30–209.7)
Orlandi et al.79
3/6 (50.0%) 0/15 (0%) 31.00 (1.29–747.03)
Siebler et al.80
1/8 (12.5%) 1/56 (1.8%) 7.86 (0.44–140.14)
Spence et al.81
5/32 (15.6%) 3/287 (1.0%) 17.53 (3.97–77.38)
Total 17/195 (8.7%) 13/949 (1.4%) 6.63 (2.85–15.44)
*Observational. Abbreviation: ACES, Asymptomatic Carotid Emboli Study.
P E R S P E C T I V E S
61. À Risque…Radiologique
Morphologie de la plaque à la Résonnance
magnétique
– Capacité de Dx rupture de cap fiberux ou hémorragie
intraplaques
– Quelques études avec peu de patients et sténose de bas grade
ont démontré augmentation du risque d’événement
– Seulement en analyse univariée
– À définir
62. Qui gagnera?
CEA, CAS may bean acceptablealternativeoption based on
the Stenting and Angioplasty with Protection in Patients at
High Risk for Endarterectomy (SAPPHIRE) trial [1].
FactorsInvolved in Clinical Decision Making
Despite the level 1 evidence in favor of CEA in general, it is
crucial torecognizethelimitationsandavoidgeneralizationor
extrapolation of results. The stroke prevention benefits with
CEA (or CAS) are dependent on 3 factors—the actual stroke
risk if carotid revascularization isdeferred, theperiprocedural
strokeor death rate, and thelifeexpectancy of theindividual.
death intheanalysis[24••]. In CREST, it wasshown that stroke
outcomeswith CEA weresignificantly better than CASamong
individuals >70 years [25]. This is an important consideration
when planning carotid revascularization in the elderly (Fig. 2).
Insummary,therisk of aperiprocedural strokewithitshighcase
fatality rate in the elderly and the lack of good evidence must
deter clinicians from recommending carotid revascularization
routinely in theelderly [26]. Rather, an individualized approach
that takesinto account lifeexpectancy, functional statusand co-
morbidities would beprudent (Fig. 2).
The epidemiology of stroke in general is different among
men and women. Women have better life expectancy but a
higher strokerisk at an older agecomparedwith men[13, 27].
Fig. 2 An algorithmic approach to management of asymptomatic carotid stenosis
64. Qui gagnera?
• Paradoxe c’est que je n’aurais pu ni gagner ni perdre
Pas gagner
• Aussi longtemps que les institutions ne reconnaisse pas la baisse
d’événements sous traitement médical rien de changera
Pas perdre
• La majorité des patients asymptomatiques n’auront jamais
d’évènement
65. À Suivre…
• A suivre…
– SPACE-2: CEA vs CAS vs BMT
– TACIT: CEA vs CAS vc BMT
– CREST-2: 2 bras: CEA + BMT vs BMT
CAS + BMT vs BMT
66. Conclusion
• Pas de concensus mondial sur le traitement optimal des
patients avec sténose asymptomatique
• Les bénéfices bien que petits démontrés dans ACAS et
ACST semblent présents
• Trop se fier sur ces données historiques peut être
inapproprié dans l’ère moderne
67. Conclusion
• Intervention de masse chez les patients
asymptomatiques prévient que peu d’évènements
neurologiques
• Plus de 90% des patients subiront des procédures non
nécessaire résultant en coût pour le système important
dans l’ère d’optimisation des ressources
• Il existe probablement un sous-groupe de patients qui
bénificierait d’une procédure mais ils demeurent à être
identifié
68. «Get your facts first, and then you
can distort them as much as you please. »
-Mark Twain
70. Considérations historiquesTable 2 | Observations that challenge the ‘one size fits all’ policy*
Year Observation
1991 40% of surgeon applicants to ACAS were rejected, raising questions about generalizability 18
1995 With a 2.3% procedural risk, CEA prevented only 59 strokes at 5 years per 1,000 CEAs in ACAS3
With procedural risk included, CEA conferred no benef t in women in ACAS3
No relationship between stenosis severity or bilateral disease and late stroke risk was
demonstrated in ACAS3
Even if you could treat every patient, 95% of all strokes in the community would still occur 70
1996 Hertzer concedes that annual risk of stroke in ACAS was much lower than had been expected71
Even with the procedural risk excluded, CEA still conferred no benef t in women in ACAS30
The f rst editorial to question whether the ACAS results warranted a tenfold increase in CEA
numbers is published12
1997 The Canadian Stroke Consortium recommends against CEA and screening 14
2000 ACAS shows that CEA does not confer signif cant benef t in patients with contralateral
occlusion35
In ACAS, 55% of late strokes were cardioembolic or lacunar; that is, the majority were not caused
by ICA embolism72
2001 Procedural risks >3% following CEA repor ted in 7 of 10 US states 19
Using ACST entry criteria; the average procedural risk after CEA in 10 US states w as 5.9%19
2002 The principle investigator of NASCET obser ved that, had ACAS data been analyzed at 4 years,
CEA would have conferred no benef t12
2003 European Stroke Initiative concludes that medical treatment is now probably the best option
for asymptomatic patients23
In an editorial, Chaturvedi suggests that the RCTs should be repeated 13
2004 In ACST, CEA conferred no benef t in patients aged >75 years4
No association between stenosis severity or bilateral disease and late stroke risk was found
in ACST4
If procedural risk was included, CEA conferred no signif cant benef t in women in ACST29
In ACST, most of the benef t was seen in patients with a prerandomization cholesterol level
>6.5 mmol/l4
Using ACST inclusion criteria, the average procedural risk after CEA in 10 US states w as 5.4%20
A meta-analysis of 46 contemporary surgical studies, demonstrated that mortality was
eight-times higher and death/stroke three-times higher compared with outcomes in A CAS21
41
nts, a number
es conferred
male sex, age
of ipsilateral
contralateral
on of patient
ated with an
S3
or ACST.4,5
oup analyses
ention. First
T to demon-
ficant benefit
vention. The
a significant
ly if the oper-
AS, however,
en when the
This apparent
of course, be
omized trials
en; however,
ACST were
CEA confer-
ent (OR1.04,
10-year data
010, females
wn to derive
The 10-year
ged <75 years
mpared with
5
P E R S P E C T I V E S
71. Considérations historiques
In ACAS, 55% of late strokes were cardioembolic or lacunar; that is, the majority were not caused
by ICA embolism72
2001 Procedural risks >3% following CEA repor ted in 7 of 10 US states 19
Using ACST entry criteria; the average procedural risk after CEA in 10 US states w as 5.9%19
2002 The principle investigator of NASCET obser ved that, had ACAS data been analyzed at 4 years,
CEA would have conferred no benef t12
2003 European Stroke Initiative concludes that medical treatment is now probably the best option
for asymptomatic patients23
In an editorial, Chaturvedi suggests that the RCTs should be repeated 13
2004 In ACST, CEA conferred no benef t in patients aged >75 years4
No association between stenosis severity or bilateral disease and late stroke risk was found
in ACST4
If procedural risk was included, CEA conferred no signif cant benef t in women in ACST29
In ACST, most of the benef t was seen in patients with a prerandomization cholesterol level
>6.5 mmol/l4
Using ACST inclusion criteria, the average procedural risk after CEA in 10 US states w as 5.4%20
A meta-analysis of 46 contemporary surgical studies, demonstrated that mortality was
eight-times higher and death/stroke three-times higher compared with outcomes in A CAS21
2005 92% of all carotid revascularizations in the USA were performed in asymptomatic patients41
2007 The US Preventive Services Task Force recommends against screening for carotid artery
stenosis (benef ts too low and do not outweigh risks)73
The annual risk of stroke in medically treated patients had been decreasing over the past
20 years16
2008 High-dose statin therapy stabilizes asymptomatic carotid plaques 42
Even with 15-year follow-up, CEA is not cost-effective in asymptomatic females, irrespective
of age31
In an NEJM poll, 50% of respondents worldwide would treat asymptomatic patients
conservatively24
Abbott suggests that it might be time to stop inter vening in asymptomatic patients15
If the procedural risk of death or disabling stroke exceeded 2.1%, or if the annual rate of fatal
or disabling stroke was <1.09%, neither CEA nor CAS would not confer any long-term benef t
in asymptomatic patients74
2009 A systematic review shows that noninterventional therapy is safer (attributed to improvements
in medical therapy) and 3–8 times more cost-effective than CEA or CAS 16
In the USA, 94% of CEA and CAS procedures w ere ultimately unnecessar y, costing $2.1 billion
per year37,40
Evidence of sustained decline in annual stroke risk in medically treated patients in ACAS
and ACST37
2010 High-dose statin therapy shown to signif cantly reduce spontaneous embolization 43
A meta-analysis of three studies (1,635 patients) shows that ipsilateral stroke risk is now only
0.5% per year75
More calls issued for RCTs comparing CEA with CAS to include a third medical arm37,76
ACST 10-year data show that ARR in stroke with CEA is only 4.6% at 10 years (0.46% per year5
)
2011 A post-CREST evaluation shows that the evidence for intervening in asymptomatic carotid artery
disease is weak and CAS should not be offered until better e vidence is available25
nly if the oper-
CAS, however,
en when the
This apparent
, of course, be
omized trials
en; however,
ACST were
CEA confer-
dent (OR 1.04,
10-year data
2010, females
wn to derive
5
The 10-year
ged <75 years
ompared with
cally,5
which
reduction in
0.58% reduc-
will question
n in stroke is
nal guidelines
nefits of CEA
he data clearly
benefit from
y selecting all
rs is probably
ost-effective31
orts to deter-
will gain the
ention.
w that patients
icant benefit
d not provide
mit for inclu-
showed that,
was excluded,
patients aged
ult of ACST
e reserved for
