What’s new in carotid intervention?

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Presentation transcript:

What’s new in carotid intervention? Theodore R. Sullivan, MD, FACS, RVT Surgical Care Specialists/Vascular

History Thomas Willis Sir Astley Cooper Ramsey Hunt Egas Moniz •  1684 •  1808 •  1913 •  1927 •  1951 •  1953 •  1980 Thomas Willis “Cerebri Anatome” Sir Astley Cooper carotid ligation Ramsey Hunt loss of pulsation and “brain softening” Egas Moniz cerebral angiogram C. Miller Fisher predicted carotid bypass Michael Debakey Mullan…first carotid angioplasty 4/5/17 2

Carotid pathophysiology •  Intimal injury tobacco, lipids, hypertension •  Shear forces at the bifurcation •  Immunocellular response to injury inflammation •  Plaque build up with potential for ulceration •  Embolization •  Thrombosis

NASCET ACAS ACST-I Medical 26% 11% 10% CEA 9% 5.5% 4.1% CEA TRIALS N Engl J Med 1991; 325:445-453August 15 JAMA. 1995 May 10;273(18):1421-8 The Lancet, 376, 2010 September:1074-84

Minimally invasive surgery, Interventional Radiology and Cardiology

Carotid stenting ‘Cheese grater effect’

Duplex imaging and CT angiography

“High risk”

CEA

Plaque ulceration 4/5/17 10

CEA

CEA at 1 week and 6 months

Vascular Quality Initiative a clinician driven database •  www.vascularqualityinitiative.org 24,201 CEAs reported in 17 regions from 2011 – 2015 •  24 % symptomatic 45 % Beta blockers, 81 % statins 30 day stroke/death 1.4 % 2.1 % MI rate LOS 1.3 days Reoperation for neck hematoma 2.0% CN injury 4.0%, 1.3 % permanent

• 2502 pts. randomized CEA v CAS with no medical arm Carotid Revascularization Endarterectomy v Stenting Trial •  2502 pts. randomized CEA v CAS with no medical arm •  Periprocedural risk CEA 2.3 CAS 4.1 1.1 Stroke MI •  No difference at 4 and 10 years

Cranial nerve injury • ECST 1739 CEAs • 3.7 % at discharge •  0.5 % at 4 month f/u

Carotid Revascularization Endarterectomy Stent Trial

Aortic arch disease

Access for carotid stenting

Restenosis?

Trans-cervical flow reversal https://www.youtube.com/watch?v=jK2lBi7QzbE

Trans-cervical flow reversal

Hybrid techniques for carotid intervention

Consensus