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Carotid Artery Stenosis Dr Pankaj Rathi DM Traine Shri Aurobindo Medical College Indore

Carotid artery stenosis and management

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Carotid Artery Stenosis Dr Pankaj Rathi DM Traine Shri Aurobindo Medical College Indore

  2. 2. Definition Carotid artery stenosis refers to a ≥ 50% stenosis of the extracranial internal carotid artery (ICA), with stenosis severity estimated using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method.
  3. 3. Carotid Artery Anatomy
  4. 4. Internal Carotid Artery It arises most frequently between C3 and C5 vertebral level, where the common carotid bifurcates to form the internal carotid and the external carotid artery (ECA)
  5. 5. Anatomical variations and segments of ICA • Variations in level of bifurcation – left higher 50% – right higher 22% – same height 28% • Variations in origin C1/2: 0.3% C2/3: 3.7% C3/4: 34.2% C4/5: 48.1% C5/6: 13% C6/7: 0.15% ICA Segments Bouthillier Classification • cervical segment • petrous (horizontal) segment • lacerum segment • cavernous segment • clinoid segment • ophthalmic (supraclinoid) segment • communicating (terminal) segment
  6. 6. Indian figures of Ischemic stroke • Prevalence rate : 545 per 100,000 • Mortality rate in stroke is 7.5 per 1000 • Carotid stenosis is an established risk factor of ischemic stroke • Atherosclerosis of internal carotid artery (ICA) is a major risk factors for stroke • Causative factor in approximately 30% of all ischemic strokes Ann Indian Acad Neurology 2015 Oct-Dec; 18(4): 412–414 Neurology India : 2017, Vol 65 Issue 2 Page : 279-285
  7. 7. Severity of The Problem in India • Asymptomatic carotid artery stenosis (ACAS) of more than 50% has a 2–6% annual risk of stroke • 5.2% of asymptomatic individuals > 40 years of age harbor significant extracranial carotid artery disease Neurology India : 2017, Vol 65 Issue 2 Page : 279-285
  8. 8. Prevalence and features of carotid atherosclerosis Neurology India : 2017, Vol 65 Issue 2 Page : 279-285
  9. 9. Natural History of Atherosclerotic Carotid Artery Disease • Extracranial atherosclerotic disease accounts for up to 15% to 20% of all ischemic strokes • Clear correlation between the degree of stenosis and the risk of stroke in the NASCET study After 18 months of medical therapy without revascularization Risk of stroke rates 19% in those with 70% to 79% initial stenosis, 28% in those with 80% to 89% stenosis 33% in the 90% to 99% stenosis Risk diminished with near-occlusion Circulation. 2011;124:e54-e130
  10. 10. Characterization of Atherosclerotic Lesions in the Extracranial Carotid Arteries and stroke Plaque morphology Ulceration, echolucency, intraplaque hemorrhage, and high lipid content Hypoechoic plaques Subcortical and cortical cerebral infarcts of suspected embolic origin Hyperechoic plaques Diffuse white matter infarcts of presumed hemodynamic origin
  11. 11. Methods of Diagnosing Carotid Artery Stenosis • Carotid Duplex Doppler • CT Angiography • MR Angiography • DSA
  12. 12. Indications for carotid duplex sonography • Cervical bruit in an asymptomatic patient • Follow-up of known stenosis (50%) in asymptomatic individuals • Vascular assessment in a patient with multiple risk factors for atherosclerosis • Stroke risk assessment in a patient with CAD or PAD • Amaurosis fugax • Hemispheric TIA • Stroke in a candidate for carotid revascularization • Follow-up after a carotid revascularization procedure • Intraoperative assessment during CEA or stenting
  13. 13. Grading Of ICA Stenosis
  14. 14. Method of Grading
  15. 15. Asymptomatic & Symptomatic Carotid Artery Disease • Asymptomatic carotid stenosis If patients lack a recent history (6 months) of ipsilateral carotid ischemic stroke or transient ischemic attack . • Symptomatic carotid stenosis Stenosis in the internal carotid artery, either intracranial or extracranial, leading to symptoms of amaurosis fugax, transient ischemic attacks, or ischemic stroke ipsilateral to the lesion • Severe stenosis (70–99%) : Highest risk for recurrent stroke or TIA Stroke. 2017;48:00-00 Curr Treat Options Cardio Med (2017) 19: 62
  16. 16. Indications for Screening Carotid Artery
  17. 17. Our Patient • Mr. X is a 74 year old man • On a statin for elevated cholesterol and ASA for primary prevention • Has attended 3-4 health check up over past 7 years to request carotid artery screening • Was told of 50% stenosis • Worried about risk for stroke • Would consider procedure to open artery if would reduce risk of stroke
  18. 18. Past Medical and Surgical History • Elevated cholesterol • Low back pain • Cervical spondylosis • GERD • BPH • S/p shoulder surgery
  19. 19. Social and Family History • Retired medical officer • Travels twice yearly from Indore to Jabalpur with wife • Helps to care for 4 grandchildren • No cigarettes • Social alcohol use, 2-3 glasses whisky/week • Family history: no cardiovascular disease or stroke
  20. 20. Medication History • Simvastatin 20 mg qd • Aspirin 81 mg qd • Omeprazole 20 mg qd • Tamsulosin 0.8 mg qhs
  21. 21. Health Examination • Well appearing • Bp 124/82, HR 72, weight 72, BMI 26.7 • Chest - clear • Cardiac – RRR no murmurs or S4 • Extremities - normal
  22. 22. Would you screen this patient for carotid artery stenosis?
  23. 23. Evaluation of Asymptomatic Patients at Risk of Extracranial Carotid Artery Disease Recommendations for Duplex Ultrasonography to Evaluate Asymptomatic Patients With Known or Suspected Carotid Stenosis Circulation. 2011;124:e54-e130
  24. 24. Duplex ultrasonography to detect hemodynamically significant carotid stenosis may be considered in asymptomatic patients with symptomatic PAD, coronary artery disease (CAD), or atherosclerotic aortic aneurysm Circulation. 2011;124:e54-e130 I IIaIIb III
  25. 25. Duplex ultrasonography might be considered to detect carotid stenosis in asymptomatic patients without clinical evidence of atherosclerosis who have 2 or more of the following risk factors: hypertension, hyperlipidemia, tobacco smoking, a family history in a first degree relative of atherosclerosis manifested before age 60 years, or a family history of ischemic stroke. However, it is unclear whether establishing a diagnosis of ECVD would justify actions that affect clinical outcomes. Circulation. 2011;124:e54-e130 I IIa IIb III
  26. 26. In a metaanalysis, DUS, MRA and CTA were equivalent for detecting significant carotid stenosis Accurate, practical and cost-effective assessment of carotid stenosis in the UK. Health Technol Assess 2006;10:iii–iv, ix–x, 1 - 182.
  27. 27. Decision making in management of carotid artery stenosis
  28. 28. Asymptomatic Carotid Stenosis: What is Medical Intervention, and Is It Effective?
  29. 29. Best Medical Therapy in Carotid Stenosis Best medical therapy (BMT) includes CV risk factor management, including best pharmacological therapy, as well as nonpharmacological measures such as smoking cessation, healthy diet, weight loss and regular physical exercise. Pharmacological component Antihypertensive Lipid-lowering Antithrombotic drugs Optimal glucose level control Eur Heart J 2007;28:2375–2414
  30. 30. Moving targets Carotid stenting has evolved. Outcomes are improving and the procedure is maturing. Randomized trials (including CREST) now supported by large post-market surveillance outcomes Medical therapy has also evolved with evidence suggesting the risk of stroke in asymptomatic patients today may be much lower than even 10 years ago
  31. 31. ASA Early 1900s Late 1900s Today ASA HTN RX 1800s ASA HTN RX (ACEI, beta blockers) DM Control, Lipid Rx ASA HTN RX Tight DM Control High dose statins ACE and ARB
  32. 32. Annual TIA and stroke in asymptomatic control arms of selected randomized trials 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% Ipsilateral stroke/ TIA Ipsilateral stroke/ TIA
  33. 33. Effect of Antiplatelet Therapy in Patients with TIA or Stroke Antiplatelet Trialists’ Collaboration. BMJ 2002;324:71-86 287 Studies: 135,000 Patients in Comparisons of Antiplatelet Rx vs Control
  34. 34. Use of ramipril in preventing stroke: double blind randomised trial BMJ VOLUME 324 23 MARCH 2002 bmj.com
  35. 35. Stroke 2009;40 • 1007 patients with carotid stenosis (not requiring revascularization) at baseline – 3271 patients had no carotid stenosis at baseline • All patients had stroke/TIA within 6 months of randomization – Randomized to Atorvastatin 80 mg/d vs Placebo • No known CHD • LDL Cholesterol between 100-190 mg/dL
  36. 36. Of those patients with carotid artery stenosis at baseline… • Atorvastatin lowered any stroke risk by 33% • Atorvastatin lowered any CHD event by 43% • Later carotid revascularization was reduced by 56%!
  37. 37. The Carotid “Prescription” • ASA 81 mg/d – No role for dual antiplatelet therapy for stroke “prevention” • Antihypertensive Therapy – ACE Inhibitor – Angiotensin Receptor Antagonist • Lipid Lowering Therapy – LDL-Cholesterol <100 mg/dL • Tobacco Cessation • Glycemic Control (HbA1C <7.0%)
  38. 38. Asymptomatic Carotid stenosis with High Risk Factors
  39. 39. Asymptomatic Carotid Stenosis with High Risk Factors
  40. 40. When Invasive Procedure ?
  41. 41. Treatment for Asymptomatic Carotid Artery Stenosis with high risk factors Revascularization  Carotid endarterectomy (CEA)  Carotid artery stenting (CAS)
  42. 42. Carotid endarterectomy (CEA)
  43. 43. Carotid artery stenting (CAS)
  44. 44. Endovascular techniques Carotid Artery Stenting Less invasive Low risk of cranial nerve injury, Wound complications Neck haematoma Carotid Endarterectomy CAS offers advantages ‘hostile neck’ (previous radiation, recurrent stenosis), contralateral recurrent laryngeal nerve palsy or in the case of challenging surgical access [very high ICA lesions, proximal common carotid artery (CCA) lesion
  45. 45. CREST (Carotid Revascularization Endarterectomy versus Stenting Trial), SAPPHIRE (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy) ACT trial ( Asymptomatic Carotid Trail )
  46. 46. ACST 10-year Follow-up Results Provide Most Rigorous Comparison Of revascularization And BMT Lancet. 2010 Sep 25; 376(9746): 1074–1084
  47. 47. Symptomatic Carotid Artery Disease
  48. 48. Symptomatic Carotid Artery Disease
  49. 49. High Risk Features for CEA & CAS
  50. 50. Failure of Medical Therapy in Symptomatic Carotid Artery Disease • 50–99% stenosis if treated medically • Increasing age (>75 years) • Symptoms within 14 days & Male sex • Hemispheric symptoms • Cortical stroke • Medical comorbidities • Irregular stenosis • Increasing stenosis severity • Contralateral occlusion
  51. 51. Timing of CEA
  52. 52. P.M. Rothwell et al. Stroke. 2004;35:2855-2861 Copyright © American Heart Association, Inc. All rights reserved.
  53. 53. Timing of CEA CEA within 14 days ( 50–69% ) ARR for stroke at 5 years ( 14.8% NNT = 7) ARR (3.3% NNT = 30)when delay was 2–4 weeks ARR (2.5% NNT 40 ) when the delay was 4–12weeks Beyond 12weeks, no strokes were prevented by CEA. CEA within 14 days ( 70–99%) ARR for stroke at 5 years was 23.0% (NNT = 4) ARR (15.9% NNT 6 ) where delays were 2–4weeks ARR (7.9% NNT 13 ) for delays of 4–12weeks ARR (7.4 % NNT 14 ) at 5 yrs when done beyond 12weeks
  54. 54. Endovascular therapy vs. open surgery • The risk of ‘any stroke’ and ‘death/ stroke’ was 50% higher following CAS, primarily because CAS was associated with a significantly higher rate of minor stroke • CAS was associated with higher periprocedural death/stroke, especially in patients >70 years of age, but with significantly lower risks for MI, cranial nerve injury and haematoma
  55. 55. Conclusion • CEA and CAS should largely be used for symptomatic patients • Most asymptomatic patients should get best medical treatment ( BMT ) & neither CAS or CAS ( except for small % ) • Except in extraordinary circumstances, carotid revascularization by either CEA or CAS is not recommended when atherosclerosis narrows the lumen by less than 50% • Carotid revascularization is not recommended for patients with chronic total occlusion of the targeted carotid artery • Carotid revascularization is not recommended for patients with severe disability caused by cerebral infarction that precludes preservation of useful function
  56. 56. THANK YOU