CAROTID ARTERY ENDARTHERECTOMY &INTERVENTION Presented By: Modaghegh M.D. (Vascular Surgeon) Mashhad Vascular Surgery Department MUMS

PRACTICE GUIDELINES 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/ SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary American Stroke Association Society for Vascular Surgery

Symptomatic Patients ECST and NASCET )1991( TIA or mild stroke and 30% to 99% ipsilateral carotid stenosis CEA and medical management Vs medical therapy alone The trial was stopped after 18 months of follow-up for patients with 70% to 99% stenosis because of a significant benefit with CEA (cumulative ipsilateral stroke risk, including perioperative stroke, was 9% at 2 years for the CEA group versus 26% with medical therapy alone). Over 5 years, the rate of ipsilateral stroke, including perioperative events, was 15.7% with CEA compared with 22% for medically managed patients Symptomatic Patients

Results of the ECST and NASCET In ECST, surgery was highly beneficial for 70% to 99% stenosis and moderately beneficial for 50% to 69% stenosis and of little benefit in patients with carotid near occlusion . [Stroke. 2003;34:514-523.]

Asymptomatic Patients ACAS CEA plus aspirin compared with aspirin without surgery. The trial was stopped after an advantage to CEA became apparent among patients with 60% stenosis (Projected 5-year rates of ipsilateral stroke, perioperative stroke, and death were 5.1% for surgical patients and 11% for patients treated medically.) Asymptomatic Patients

Overview of the Asymptomatic Carotid Atherosclerosis Study (ACAS). patients with asymptomatic stenosis of 60% or greater to either carotid endarterectomy and aspirin or aspirin alone. Study was interrupted because of a significant benefit identified in patients undergoing carotid endarterectomy. [JAMA 273: 1421, 1995.]

Asymptomatic Patients ACST immediate versus delayed CEA 3.1% 30-day risk of stroke or death in either group, Five-year rates were 6.4% for the early-surgery group versus 11.7% for the group initially managed medically The benefit of surgery today may be less than in the early trials, and the 3% complication rate should be interpreted in the context of advances in medical therapy. Asymptomatic Patients

Carotid Endarterectomy THE GOLD STANDARD FOR SYMPTOMATIC AND ASYMPTOMATIC PATIENTS WITH CAROTID ARTERY STENOSIS

CONTRA INDICATIONS FOR CAROTID ENDARTHERECTOMY

Contra indications Short life expectancy Rutherford 2006 Acute major stroke without improvement Previous major stroke with decreased consciousness or worsening of Neurologic symptoms Vertebrobasilar TIA Multi infarct dementia Sabiston 2007 Severe neurologic difficulties Large infarction Intra cranial hemorrhage

CEA

Monitoring for the need of carotid shunt Awake patients EEG Stump pressure Cerebral oximetry

Protection Coronary stenting or combined operation Serious heart problem Acceptable tolerance Intact Willis circle Cervical block Acceptable patency of other vessels Serious medical problems Cervical block to avoid of BP fluctuation Low cardiac compliance Old age

Cervical Block

Position

Quality of anesthesia by CB

Quality of anesthesia by CB

Administration of Manitol Protection Shunt General Anesthesia O2 100% Increase of BP Dexamethason Clamping Heparin Operation completed Administration of Manitol

Protection Before sinus stimulation 1 cc Lidocain Foley catheter During surgery NG or Dopamine for Control of hypertension or hypotension Administration of Aspirin before, during and after of surgery

Anatomy Carotid body tumor Vagus nerve Carotid bifurcation Hypoglossal nerve Jugular vein SCM

Shunt

Plaque during surgery

Plaque Resection

Plaque Resection

Complete Obstruction

Repair of Artery

CEA Vs CAS The EVA-3S (Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis) within 120 days of TIA or stroke + 60% stenosis outcome was stroke or death within 30 days Enrollment stopped in 2005, with 520 patients enrolled, because of higher 30-day rates of stroke and adverse events in the CAS arm. CEA Vs CAS

Table 7. Summary of Recommendations Regarding the Selection of Revascularization Techniques for Patients With Carotid Artery Stenosis Symptomatic Patients Asymptomatic Patients 50% to 69% Stenosis 70% to 99% Stenosis* Endarterectomy Class I Class IIa LOE: B LOE: A Stenting Class IIb

ICSS: Stroke severity by treatment allocation End point CAS CEA Fatal stroke 9 2 Disabling stroke 17 19 Nondisabling stroke 39 14 End point CAS, n (%) CEA, n (%) Hazard ratio (95% CI) New ischemic lesions 50 (46.3) 13 (14.1) 5.24 (2.61–10.53) CAS=carotid artery stenting CEA=carotid endarterectomy Brown MM et al. European Stroke Conference 2009; May 27, 2009; Stockholm, Sweden. 29

Symptomatic patients have a higher risk than asymptomatic patients (OR 1.62; p0.0001), as do those with hemispheric versus retinal symptoms (OR 2.31; p0.001), urgent versus nonurgent operation (OR 4.9; p0.001), and reoperation versus primary surgery (OR 1.95; p0.018)

Cerebral Protection Devices For CAS: Distal occlusion balloon Distal filter Proximal protection with flow stasis or reversal

Distal occlusion balloon

:Distal filters

40

Proximal protection with flow stasis (Mo.Ma system)

Proximal protection with flow reversal: (Reverse flow to femoral vein) Gore Flow Reversal System MICHI Neuroprotection System

Thanks for your attention