Epidemiology in HK Stroke is major cause of morbidity and mortality around the world 4th cause of...
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Transcript of Epidemiology in HK Stroke is major cause of morbidity and mortality around the world 4th cause of...
Epidemiology in HK
Stroke is major cause of morbidity and mortality around the world
4th cause of mortality in HK resulting in >3000 deaths every year
Department of Health 2011
Stroke
80 % of strokes : ischaemic in orgin 20 – 25 % of ischaemic stroke : carotid stenosis Risk of stroke correlates with severity
of carotid stenosis
Treatment options
Medical therapyMedical therapy
Carotid Carotid endarterectomyendarterectomy
Carotid artery Carotid artery stentingstenting
Carotid Endarterectomy (CEA)
First described in 1953 Widely used invasive treatment for significant
carotid stenosis Efficacy was established by 4 RCTs in late 1980s
and early 1990s
CEA superior to medical therapy
Symptomatic carotid stenosis North American Symptomatic Carotid Endarterectomy Trial (NASCET)
Carotid stenosis 70 – 99% : 2 yrs stroke reduced from 26% to 9% (p<0.001) Carotid stenosis 50 – 69% : 2 yrs stroke reduced from 22.2% to 15.7%
(p<0.045)Carotid stenosis <50% : no benefit
European Carotid Surgery Trial (ECST)
JM Henry N Eng Jounral of Medicine 1998
PM Rothwell Lancet 1998
CEA superior to medical therapy
Asymptomatic carotid stenosis Asymptomatic Carotid Surgery Trial (ACST)
Carotid stenosis >60% : 5 yrs stroke rate reduced from 11.8% to 6.4%
10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1)
10 yrs stroke rate reduced from 17.9% to 13.4%
Asmptomatic Carotid Atherosclerosis Study (ACAS)
A. Halliday Lancet 2004
JAMA 1995
A. Halliday Lancet 2010
Carotid Endarterectomy (CEA)
Emerge of Carotid artery stenting (CAS)
1. Excluded elderly patients (>80 yrs) with significant comorbidites
2. Excluded high risk lesions such as restenosis after prior CEA, radiation induced stenosis ...
3. CEA associated complications such as cardiovascular events, wound complications, cranial nerve injury, carotid artery dissection...
Carotid artery stenting (CAS)
First case report of carotid angioplasty appeared in early 1980
Embolic-protection device in distal artery
Balloon angioplasty across stenotic area
Deployment of stent
Withdrawl of embolic –protection device
1st RCT (CEA Vs CAS)
Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS) Performed only angioplasty without EPD NO significant difference in 30-day incidence of
death or disabling stroke (6.4% in CAS vs 5.9% in CEA)
8 yrs follow up : Higher restenosis and stroke rate (21.1% in CAS vs 15.4% in CEA)
CAVATAS Investigators Lancet 2001
CAVATAS Investigators Lancet 2009
RCTssssssss (CEA Vs CAS)
TrialTrial No of No of patientspatients
FindingFinding ConclusionConclusion
SPACE 1200 30 days stroke and death rateCAS : 6.84%CEA : 6.34% (p = 0.09)
Failed to prove non-inferiorty of CAS
EVA – 3S 527 30 days stroke and death rateCAS : 9.6%CEA : 3.9% (p = 0.01)
Terminated early due to high stroke rate in CAS group
ICSS 1700 120 days stroke, MI and death rateCAS : 8.5%CEA : 5.2% (p = 0.006)
CEA should remain the treatment of choice
RCTssssssss (CEA Vs CAS)
SPACE, EVA-3S and ICSS were widely criticizedwidely criticized NO roll in phase e.g. SPACE trial : eligible operators for CAS arm do
not need prior carotid stenting experience
Use of EPD was not mandatory e.g. SPACE trial : used in 27% of patients
CREST Trial
Stenting versus Endartrectomy for Treatment of Carotid – Artery Stenosis (CREST)
National Institutes of Health-sponsored study based in United States from 2000 to 2008
2522 patients including both symptomatic and asymptomatic carotid stenosis Lead in phase Single carotid stent with EPD systems
Thomas G. Brott N Eng Journal of Med 2010
CREST – Periprocedural finding
OutcomeOutcome CEA %CEA % CAS %CAS % p valuep value
Periprocedural stroke+MI+death 4.5 5.2 0.38
Periprocedural stroke- Major ipslateral stroke- Minor ipsilateral stroke
2.30.31.4
4.10.92.9
0.010.09
0.009Periprocedural MI 2.3 1.1 0.03
Periprocedural death 0.3 0.7 0.18
Periprocedural cranial nerve injury 4.8 0.3 0.0001Thomas G. Brott N Eng Journal of Med 2010
CREST – 4 years finding
OutcomeOutcome CEA %CEA % CAS %CAS % p valuep value
4 years stroke+MI+death 6.8 7.2 0.51
4 years stroke 2.3 2 0.085
Thomas G. Brott N Eng Journal of Med 2010
CREST Finding – Age
Thomas G. Brott N Eng Journal of Med 2010
Younger patients have better outcome with CAS while older patients have better outcome with CEA
120 days stroke and death risk Age <70 yrs : CAS – 5.8% CEA – 5.7% Age >70 yrs : CAS – 12% CEA – 5.9%
Arterial tortuosity and calcification in elderly prones to catheter provoked cerebral emboli
CEA = CAS ??
Are these conclusion justified?
1. Primary purpose of CEA and CAS is to prevent death and stroke
OutcomeOutcome CEA %CEA % CAS %CAS % p valuep value
Perioperative stroke+MI+death 4.5 5.2 0.38
Perioperative stroke- Major ipslateral stroke- Minor ipsilateral stroke
2.30.31.4
4.10.92.9
0.010.09
0.009Perioperative MI 2.3 1.1 0.03
Perioperative death 0.3 0.7 0.18
Perioperative cranial nerve injury 4.8 0.3 0.0001
Are these conclusion justified?
2. Stroke ≠ Myocardial Infarction Quality-of-life analyses indicates that stroke had a greater adverse effect on heath-status than MI Even minor stroke had full motor and sensory recovery, patient often have other brain damage
Are these conclusion justified?
3. CAS operators in CREST have a high level of experience and skill, CREST results may not be representative in real world
Carotid Endarterectomy Carotid Endarterectomy (CEA)(CEA)
Carotid Artery Stenting Carotid Artery Stenting (CAS)(CAS)
Pros Cons Pros Cons
Periprocedural stroke
MI Periprocedural MI
Periprocedural stroke
Cranial nerve injury No cranial nerve injury
Wound infection Wound infection
Required GA No GA required
Longer recovery Minimally invasive
Matching patient to intervention Treatment decisions depends on patient-
specific factors1. Risk factors for CEA 2. Risk factors for CAS
Medical
Surgical / Anatomical
Risk factors for CEA Medical risk factorsMedical risk factors CHF and left ventricular
dysfunction Unstable angina or recent MI (<30
days) Coronary artery disease (CAD) Open heart surgery needed within
6 weeks Severe pulmonary dysfunction
Mozes J Vasc Surg 2004
risk of worse outcome remains controversial Similar stroke and death rate between low
and high risk patient Too high risk Medical treatment
Risk factors for CEA Surgical / Anatomical risk factorsSurgical / Anatomical risk factors
Surgical FactorsSurgical FactorsRestenosis after prior CEAPrevious ablative neck surgery (e.g. radical neck dissection, laryngectomy)Previous neck irradiationContralateral vocal cord paralysisTracheostomy
Risk factors for CEA Surgical / Anatomical risk factorsSurgical / Anatomical risk factors
Anatomical FactorsAnatomical FactorsHigh carotid bifurcation (above C2)Extension of athersclerotic lesion into intracranial ICA or proximal CCA below clavicle
Risk factors for CAS
Individualized management Optimal treatment selection specific for each
patient Lowest morbidty rateLowest morbidty rate Most favorable outcomesMost favorable outcomes
Management Algorithm
HIGH risk HIGH risk for surgeryfor surgery
Favourable
anatomy for CAS
CACASS
Unfavourable anatomy
for CAS
CEACEA
Symptomatic >= Symptomatic >= 50% CS50% CS
LOW risk for LOW risk for surgerysurgery
Asymptomatic >= Asymptomatic >= 70% CS70% CS
BMTBMT
Conclusion
CEA continues to be the gold standard for treatment for carotid stenosis
CAS will evolve as a safe and efficacious therapy for carotid stenosis
Individualized treatment plan