Selecting Patients Best Suited for CEA Nick Hopkins MD Mandy Binning MD Elad Levy MD Adnan Siddiqui MD, PhD Dept of Neurosurgery SUNY Buffalo

L. Nelson Hopkins, MD DISCLOSURES Consulting Fees Abbott Vascular, Bard Peripheral Vascular, Boston Scientific Corporation, Micrus Endovascular Cordis, a Johnson & Johnson company Grants/Contracted Research Cordis, a Johnson & Johnson company, Boston Scientific Corporation, Micrus Endovascular Honoraria AccessClosure, Inc., Bard Peripheral Vascular, Boston Scientific Corporation, Cordis, a Johnson & Johnson company, marketRx, Inc., Micrus Endovascular, Medsn Ownership Interest (Stocks, Stock Options or Other Ownership Interest) APW Holding, Inc., Boston Scientific Corporation, Magellan Spine Tech, Inc., MedFocus Accelerator Fund, Micrus Endovascular

Carotid Endarterectomy The most studied operation in the world

CEA CEA is effective in reducing risk of stroke in carefully selected patients with symptomatic carotid stenosis ≥ 50% or asymptomatic carotid stenosis ≥ 70% Many variations on CEA technique are in use, but none have been proven to be superior Certain subgroups are at higher risk of complications with CEA

Symptomatic Carotid Stenosis NASCET 70-99% stenosis: 17% (26 to 9%)ARR (65% RRR) / 2 yrs 50-69% stenosis: 6.5% ARR (29% RRR) / 5 yrs <50% stenosis: no benefit Favors CEA for 50-99% symptomatic stenosis 13.1% vs. 2.5% with CEA for major ipsilat. CVA ECST (reanalysis by NASCET criteria, Lancet 2003;34:514) 3,024 pts w/ TIA, retinal infarction, or non-disabling stroke within 6 months 70-99% stenosis: 21.2% ARR / 5 yrs 50-69% stenosis: 5.7% ARR / 5 yrs <50% stenosis: no benefit (harm if <30% stenosis)

Outcome after CEA depends on risk for perioperative complications NASCET: 30-day rate of disabling stroke and death was 2.9% ECST 30-day rates disabling stroke: 2.5% death: 1.0%

Asymptomatic RCT’s: Best Med Tx ± CEA ACAS (JAMA 1995;273:1421) 1,662 pts w/ angio or validated doppler > 60% 5.9% ARR (53% RRR) / 5 yrs required low surgical M&M (1.5%) no stat. sig. benefit for women ACST (Lancet 2004;363:1491) 3120pts w/ doppler > 60% stenosis 5.4% ARR (11.8→6.4% risk) / 5 yrs results more robust than ACAS surgical M&M (3.0%)

AHA Recommendations CEA in symptomatic patients should be undertaken by surgeons whose surgical morbidity and mortality rate is <6% Moore et al., Stroke 26:188-201, 1995

High-Risk features for CEA Anatomical C2 and higher lesion Contralateral carotid occlusion / stenosis (is relative) Severe ulceration Tandem intracranial stenosis Functional Age > 80 (some say 75) Active coronary artery disease (before intervention) Recent major stroke in reference vascular territory

AHA Recommendations CEA in asymptomatic patients should be undertaken by surgeons whose surgical morbidity and mortality rate is <3% Moore et al., Stroke 26:188-201, 1995

Patient Evaluation CEA is most effective when patients are selected appropriately NASCET, ECST, VACS: patient eligibility was based on angiographic criteria Furthermore, CEA in asymptomatic patients carries a narrow risk-benefit ratio, making accurate patient selection essential

Carotid Duplex Ultrasonography: Limitations Significant proportion of CEAs are performed in centers without designated, accredited vascular labs Goldstein Stroke 26:1607-1615, 1995 Even accredited, high-volume vascular labs may report false-positive results for carotid stenosis in 20-41% of cases Qureshi Stroke 32:2287-2291, 2001 Duplex scanning cannot accurately distinguish preocclusive disease from total occlusion Dawson J Vasc Surg 18:673-683, 1993 Duplex scanning does not indicate whether the lesion is relatively high in the cervical region, which is information that is important for surgical planning Duplex scanning does not image the intracranial vasculature

Radiographic Evaluation Doppler alone is NOT enough MRA or CTA + Doppler ok if congruent Angio still gold standard for anatomy and collateral circulation

Degree of Stenosis – Asymptomatic Stenosis ACAS: No effect of degree of stenosis on risk of stroke or perioperative risk Stroke 20: 844–849, 1989 NASCET: Risk of stroke ipsilateral to asymptomatic side did correlate with stenosis Barnett et al., Neurology 46:603–608, 1996 Figure: Barnett et al., Neurology 46:603–608, 1996

Multicenter Review of Preoperative Risk Factors for CEA in Patients with Symptomatic Stenosis 1,160 CEAs performed at 12 academic medical centers 697 patients with ipsilateral symptoms 8.5% had either stroke, MI, or died during the postoperative period of hospitalization. Those >75 yo had a greater risk of MI (6.6% vs 2.3%, P=.024) but not of stroke or death (P>.10) Variables with >90% probability of being associated with adverse outcomes age ≥75 years angiographic evidence of ipsilateral carotid occlusion stenosis in the region of the carotid siphon intraluminal thrombus Goldstein et al., Stroke 25:2096-2097, 1994

Endarterectomy in the Elderly 11,973 CEAs No significant difference in stroke rate in patients aged < or > 75 yo Mortality 2.14% in >75 yo vs 0.88% in <75 yo (P =.0001) Maxwell et al., Am J Surg 1997;174:655-660

Heart Disease Patients with coronary artery disease are also at an elevated risk of perioperative stroke and death, with an incidence as high as 40% Ferguson et al., Stroke 24:1285-1291, 1993

Subgroup Analysis: Ulcerated Plaque NASCET: Risk of perioperative stroke or death was 1.5 times higher in the presence of an ipsilateral ulcerated plaque Ferguson et al., Stroke 30:1751-1758, 1999

Intracranial Stenosis ACAS: Presence of contralateral carotid siphon stenosis was associated with a significantly higher risk of perioperative stroke after CEA Young et al. Stroke 27:2216-2224, 1996

Contralateral Occlusion NASCET: Perioperative risk of stroke and death is increased in the presence of contralateral carotid occlusion (14.3% vs. 4.0%) Gasecki et al. J Neurosurg 83:778-782, 1995

Absence of Collateral Circulation NASCET: Risk of perioperative stroke in patients with an absence of collaterals on angiography is increased by a factor of 4 (4.9% vs. 1.1%) Henderson et al. Stroke 31:128-132, 2000

Intraluminal Thrombus NASCET: 30-day stroke risk for CEA in patients with an intraluminal thrombus was 12.0% Villareal et al., Stroke 29:276, 1998

CAS Risk Factors CEA a Better Alternative than CAS + Filter Sx (hot) lesion… Elderly pts… ?? Low GSM… Multiple stents… Duration Filter… Pre dil without EP … Tortuousity- severe… Concentric calcium… Aortic Arch disease… Renal Failure...

Conclusions CEA: a good operation CEA: great alternative for most high risk CAS pts Acceptable risk: 3% Asx and 6% Sx CEA Risk factors/pts to avoid CEA Body habitus, high & low lesions Medical comorbitities: cardiac, resp Hostile neck Severe intracranial ds/poor collateral circulation Neurologic instability

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