«НОВЫЙ» ВЗГЛЯД НА «СТАРЫЕ» ПРОБЛЕМЫ В КАРОТИДНОЙ ХИРУРГИИ

European Society for Vascular Surgery. XXVI Annual Meeting. 19-21 September 2012. Bologna. Italy.

ГРАЧЕВ С.А., СТАРОВЕРОВ И.Н. Областная клиническая больница

г. Ярославль

Ташкент, 12-13 ноября 2013 год

Is intervention dead in asymptomatic disease?

Professor Jean – Baptiste Ricco Hospital Jean Bernard, Poitiers, France

«Why not just treat them with aspirin and statins first

and wait for symptoms!»

Professor Peter R F Bell

CONTRALATERAL OCCLUSION ACST - 2004

Patients with contralateral occlusion who had immediate surgery had a benefit compared to those with deferred surgeryStroke rate:1.5% (1/147) vs. 10/1 % (10/128), OR :[1.9-15.4%]

SILENT INFARCTS ON MRI/CT

Patients with silent infarcts on CT scan have a threefold excess risk (3.6 % vs. 1%, p=0.02) of late ipsilateral strokeACSRS study

PLAQUE ECHOLUCENCY ON ULTRASOUND Low Gray scale median

score are associated with echolucent plaques which were also shown to be associated with infarction on CT-Scan

Combination of TCD microemboli and plaque echolucency could identified a high-risk group

TRANSCRANIAL DOPPLER MICROEMBOLI DETECTION

Embolization and late ipsilateral stroke in ACSSTUDY N STROKE

TCD+STROKETCD-

OR [95% CI]

ACES* 467 5/77 (6.5%) 5/390 (1.3%) 5.3 [1.5-18.9]

ABBOTT 231 2/60 (3.3%) 4/171 (2.3%) 1.4 [0.3 - 8.0]

SPENCE 319 5/32 (15.6%) 3/287 (1.1%) 17.5 [3.9 - 77.4]

*ACES, Asymptomatic Carotid Emboli Study

ULCERATION ON 3D ULTRASOUND 3D Ultrasonography can

reliably detect ulceration in the carotid artery

The 3-year risk of stroke in patients with ACS increases with the number of carotid ulcers

Ulcer on 3D Ultrasound

Stroke at 3-year

0 1.9%

1 4.4%

2 7.1%

≥3 18.2%

MAGNETIC RESONANCE IMAGING

A univariate cox regression analysis showed that in a group of patients with ACS, intraplaque hemorrhage on MRI was associated with a threefold increased risk of ipsilateral stroke

SOURCE

CONDITION OR

Takaya Intraplaque hemorrhage 5.2

Thin or ruptured fibrous cap

17

Large lipid necrotic core 1.6

POSITRON EMISSION TOMOGRAPHY

Fluoro-deoxyglucose-PET has been used to visualize inflamed high-risk carotid plaques.

FDG uptake has been used in clinical research as a biomarker of carotid plaque inflammation

CONCLUSIONS

1. A small, but significant benefit , for CEA was observed in ACAS and ACST.2. Mass interventions in asymptomatic patients prevent very few strokes and more than 90% of these patients will undergo an unnecessary intervention costing enormous sums of money.3. We have the responsibility to identify who really does benefit from intervention.

SUGGESTIONS

1.Contralateral symptoms or occlusion2.Silent infarct3.Plaque echolucency4.TCD microemboli detection5.Ulceration on 3D ultrasonography6.MRI for intra-plaque haemorrhage7.PET scan for plaque inflammation

Carotid endarterectomy: urgent vs. delayed treatment

in recently symptomatic patients

Professor A Ross Naylor.University of Leicester, UK

ESVS Guidelines 2009

CEA is recommended…….preferably within 2 weekof the patient's last symptoms

EJVES 2009

Evidence A

AHA Guidelines 2010 Furie Stroke 2010

When CEA is indicated for TIA/stroke, surgery within two weeks is «reasonable» if there are no contraindications to early revascularization

Evidence B

«COMFORT ZONE»

early risk of stroke after TIA is low+

AHA=treatment<6 months acceptable+

procedural risk lower if CEA is delayed+

how can I learn CAS if I have to intervene early=

NO real incentive to intervene early

THE REALITY

The benefit conferred by CEA (CAS) declines rapidly as delays to treatment occur

The natural history risk of stroke after TIA is very much higher than previously thought

STROKES PREVENTED AT 5 YEARS /1000 CEAS

<2 wks 2-4 wks 4-12 wks >12 wks0

20

40

60

80

100

120

140

160

180

200

6000 patients from VA,ECST%NASCET

NASCET 50-99%

STROKE AFTER TIA?500 strokes which were preceded by a TIA. When did stroke occur?

NATURAL HISTORY RISK OF EARLY STROKE

STROKE RISK AFTER TIA (50-99 % STENOSIS)

48 h 72 h 7d 14d

FairheadNeurology

2005

20%

OIS Stroke2009

17%

22% 25%

Johansson Int J Stroke 2012

5,2% 7,9% 11,2%

WHY?Marshall &Harrison BJS 1977

CEA <4 weeks66% have overlying

thrombus

CEA >4 weeks21% have overlying

thrombus

WHO WOULD YOU RATHER HAVE?

Surgeon A

who performs CEA within 2 weeks witha 10% risk of death/stroke

orSurgeon B

who waits 4 weeks but when operates witha 0% procedural risk

DELAY, PROCEDURAL RISK & PATIENTS BENEFIT

ASK YOURSELF THIS…

If you suffered a TIA and were found to have a50-99% stenosis, would you want your CEA orCAS deferred or would you seek an urgent

intervention?

Thank you for attention!