Chapter 92 - Carotid artery stenting Flashcards
first proposal of carotid angioplasty
Mathias 1977
First proposal of CAS
1987 Marks
stroke rate 6-9%
First use of cerebral protection devices
1990 Theron
Key RCT comparing CAS and CEA
1) SAPPHIRE
2) EVA-3S
3) SPACE
4) ICSS
5) CREST
6) ACT-1
SAPPHIRE (US)
Stenting and angioplasty with protection in patients at high risk for endarterectomy
1) 2004, 2008
2) 334 patients
3) > 50% symptomatic or > 80% asymptomatic
4) EPD use 97%
5) primary: composite death, stroke, MI 30 days or ipsi stroke 1 year
6) 1 year 12.2% vs 20.1%; 3 eyar 24.6 vs 26.9% CAS vs CEA
7) non-inferior, not superior
EVA 3S (FRENCH)
Endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis
1) 2006, 2008
2) 527 patients
3) > 60% symptomatic only
4) EPD 92%
5) primary: any stroke/death 30 days
6) 30 day: 9.6 vs 3.9%; 6 months 11.7 vs 6.1%; 4 year 11.1 vs 6.2%
7) CAS worse stroke/death
trial stopped early
much worse if no EPD used
criticism: not trained IR people
SPACE trial (GERMAN)
Stent-supported percutaneous angioplasty of the carotid artery versus endarterectomy
1) 2006, 2008
2) 1200 patients
3) > 70% symptomatic
4) EPD 27%
5) primary: ipsi stroke death 30 days
6) 30d 6.8 vs 6.3%; 2 year 9.5 vs 8.8%
7) higher risk periprocedural with CAS
stopped early due to cost
fail to show non-inferiority
higher rate of restenosis
ICSS (UK)
International carotid stenting study
1) 2010, 2015
2) 1713 patients
3) > 50% symptomatic
4) EPD 72%
5) primary: 3 year fatal or disabling any stroke
6) 120 days 8.5 vs 5.2%; 4.2 year 6.4 vs 6.5%
7) long term risk of disabling stroke similar
CREST (US)
Carotid revascularization endarterectomy versus stenting trial
1) 2010, 2016
2) 2502 patients
3) carotid stenosis > 70% on ultrasound or symptomatic > 50% on angio
4) EPD 96%
5) composite stroke, MI, death 30 days or ipsilateral stroke 4 years
6) 4 year 7.2 vs 6.8%; 10 year 11.8 vs 9.9%
7) no sig long term difference between the two in composite endpoint or risk of stroke
risk of stroke/death higher in symptomatic patients getting CAS
6 vs 3.2%
ACT-1 (US)
Carotid angioplasty and stenting versus endarterectomy in asymptomatic subjects who are at standard risk for carotid endarterectomy with significant extracranial carotid stenotic disease
1) 2016
2) 1453 patients
3) > 80% asymptomatic carotid stenosis
4) EPD 100%
5) primary: composite death, stroke, MI, 30 day or ipsi stroke 1 year
6) 30d: 2.9 vs 1.7%; 1 year 3.8 vs 3.4%
7) CAS not inferior
ACA/AHA recommendation for symptomatic carotid stenosis with CAS
1) CAS is alternative if average risk, > 70% imaging or > 50% DSA
2) CAS in > 70% stenosis with high risk comorbidity or neck hostility
3) periprocedural morbidity/mortality < 6%
SVS on CAS in symptomatic disease
1) CAS in > 50% stenosis and hostile neck/previous nerve injury or beyond clavicle-C2 lesion
2) > 50% stenosis and uncorrectable CAD, CHF, COPD
ESC guideline on CAS in symptomatic disease
1) CAS alternative if high surgical risk
2) death/stroke rate < 6% by operating site
ACC/AHA on asymptomatic CAS
1) >60% angio or > 70% doppler
2) not clear if better than BMT
SVS on asymptomatic CAS
1) 70-99% stenosis
2) CAS only if stroke/death < 3% at the centre
ECS on asymptomatic CAS
1) > 60%
2) < 3% death/stroke rate
Center for medicare and medicaid service on CAS
1) symptomatic > 70% if high risk for CEA
2) symptomatic 50-70% if enrolled in trial
3) asymptomatic > 80% if enrolled in trial
Definition of patients high risk for CEA
1) CHF class 3-4
2) LVEF < 30
3) unstable angina
4) contralateral carotid occlusion
5) recent MI
6) previous CEA
7) previous radiation
Evidence on CAS with age
SPACE post-hoc
ipsi stroke death 2.7% < 68 yo
10.8% > 68 yo
CEA similar
CREST post-hoc
composite outcome increase 1.77x per 10 yr increment
overall higher risk when > 70 years old
evidence on CAS with sex
CREST showed women did worse with stroke in CAS
other trials did not
higher debris size captured in EPD for women
? symptomatic women higher risk for CAS?
Absolute contraindication to CAS
1) visible thrombus in carotid lesion
2) active infection
3) inability to gain vascular access
Relative contraindication to CAS
1) older age
2) circumferential carotid plaque with calcification
3) severe tortuosity with 2x 90 degree angles
4) near occlusion (string sign)
5) inability to deploy protection device
3 types of aortic arch morphology
TYPE 1: great vessels arise at or above the horizontal place as the outer curvature of arch
TYPE 2: origin of innominate between horizontal plane of inner and outer curve
TYPE 3: innominate lies below horizontal plane of inner curvature
Stroke rate increase in CAS if ICA-CCA angulation > 60 degrees
4.96 x
Plaque length on risk of CAS stroke
EVA-3S trial: > 10 mm causes 2.36x risk of stroke
CREST: > 12.85 mm causes 3.42x risk of stroke
timing of CAS after event
EVA-3S, SPACE, ICSS pooled analysis: highest risk of CAS in first 7 days
Carotid acculink/accunet post-approval trial to uncover unanticipated or rare events (CAPTURE) registry - worse outcome of CAS in 0-13 days
CAS done in first 4 weeks 6% vs > 4 weeks 8% composite outcome similar
inconclusive on timing but maybe not right away
ROADSTER trial
Test ENROUTE neuroprotective system using transcarotid artery revascularization TCAR
1) 208 patients
2) symp > 50% or asymp > 70%
3) stroke 1.4%
Steps in TFCAS
1) 6F 90cm sheath in descending aorta
2) catheter cannulate CCA
3) 035 wire into mid CCA
4) catheter advance to just below bifurcation
5) sheath advanced as well
6) 014 buddy wire in ECA may help maintain platform in position
7) angiogram and EPD
8) Predilation 2.5-4 mm coronary balloon to 4-6 atm maybe necessary
9) deliver stent
10) retrieval of EPD and angiogram
11) maybe nitroglycerin 100-200 mcg
Types of embolic protection devices
1) Filter-type EPD
- uninterrupted cerebral blood flow
- low number of manipulations in carotid vessel
- have to traverse carotid lesion for deployment
2) distal occlusion balloon (Theron et al)
- balloon occlude antegrade flow in distal ICA
- needs removal after suctioning out debris
- still has to traverse lesion
3) proximal protection EPD
- Mo.Ma: occlusive balloon in CCA and ECA
- suction dry before deflating
- ENROUTE TCAR: flow reversal with filter
- prevent need for crossing lesion
- larger sheath needed
Percentage of patients that cannot tolerate flow reversal
5-9%
Types of carotid stents - material
1) stainless steel (cobalt alloy)
2) nitinol (nickel-titanium): higher radial force
Types of carotid stents - struts
1) open cell: more conformable/flexible
2) close cell: better scaffolding of vessel wall
Sizing of carotid stents
to the largest portion of artery = distal CCA
Effect of post-dilation
- 1x increase hemodynamic depression
- 4x increase in stroke/death
reserved for severe residual stenosis
Treatment of post angioplasty hypotension
Atropine iv 0.4-1mg
phenylephrine 1-10 mcg/kg
dopamine 5-15 mcg/kg/min
Risk for persistent hypotension post-CAS
1) lesion from bifurcation to max stenosis < 1cm
2) eccentric stenosis
3) echogenic plaque morphology
4) calcified carotid bifurcation
Antiplatelet therapy in CAS
DAPT 4 days prior and for 30days minimum post
Ticlopidine 250 BID can replace plavix
Anticoagulation in CAS
no indication
RCT showed worse effect that was terminated early
statin in CAS
CV events lower with statin 4 vs 15%
stroke and death 1.5 vs 4%
Technical complications of CAS
1) stent thrombosis - convert to CEA
2) kinking - observe if mild
3) carotid dissection - additional stent
neurological complication of CAS
1) embolism - embolic retrieval, tpa, aspiration, glycoprotein IIb/IIIa receptor inhibitor
2) intracranial hemorrhage
3) hyperperfusion
Microembolic events in CAS subclinical rate
71% vs 4% CEA
Rate of stent fracture in CAS
9% 0-37 months after surgery
Carotid and vertebral artery transluminal angioplasty study CAVATAS on 10 year restenosis rate
30.7% compared to 11% CEA
26% if just stent not POBA
CREST on restenosis of CAS
6% vs 6.3% CEA more comparable
Risk of CAS restenosis factors
1) longer lesion > 0.65 of CCA diameter
2) DM
3) female
4) dyslipidemia
Ongoing trials on CAS
1) SPACE-2: BMT vs intervention and CAS vs CEA
- primary outcome: stroke/death 30d and stroke ipsi 5yr
2) ACST-2: CAS vs CEA in asymptomatic
- 30d MI/stroke/death; 5yr stroke
3) ECST2: BMT vs CAS/CEA with > 50% stenosis
- asymp or symp
- primary any stroke/death 30d
4) CREST2: BMT vs revasc asymp > 70%
- BMT vs CAS
- BMT vs CEA
- primary stroke/death 44d; ipsi stroke 4 yr
5) ROADSTER2: TCAR study
- primary 30d procedure
- stenosis > 50% symp or > 80% asymp
