Hind Alnajashi

C AROTID ARTERY ANATOMY Common carotid artery Aortic arch Internal carotid MCA ACA Ophthalmic artery. Cervical segment Petrous segment Caveronus segment Cisternal segment Cerberal segment

M ECHANISM OF SYMPTOM low-flow due to the stenosis embolism of the thrombotic material

Carotid endaryerectomy is the most commonly performed procedure to minimize further stroke risk in patient with carotid atherosclerosis.

History $ examination Sign & symptom of carotid artery territories ischemia YES NO Symptomatic carotid artery stenosis asymptomatic carotid artery stenosis In the large clinical trials addressing the management of carotid artery stenosis, the detection of "silent" infarcts on CT or MRI did not qualify the stenosis as symptomatic. In clinical practice, however, radiographic evidence of ischemia in the territory of a stenotic internal carotid artery may affect management.

C AROTID ENDARTERECTOMY IN ASYMPTOMATIC PATIENTS Three high-quality major trials : Veterans Affairs Cooperative Study Group. Asymptomatic Carotid Atherosclerosis Study (ACAS). Asymptomatic Carotid Surgery Trial (ACST).

VA STUDY — T HE V ETERANS A FFAIRS (VA) C OOPERATIVE S TUDY G ROUP presented the first evidence supporting the use of CEA in asymptomatic patients with carotid stenosis. multi-center trial randomly assigned 444 men with 50 to 99 percent asymptomatic carotid stenosis, as assessed by arteriogram, to aspirin alone or aspirin plus CEA. The end point of the trial was the combined incidence of TIA, transient monocular blindness, and stroke.

VA STUDY — T HE V ETERANS A FFAIRS (VA) C OOPERATIVE S TUDY G ROUP After an average follow-up of almost 48 months, the CEA plus aspirin group compared with aspirin alone showed the following outcomes : A significantly lower incidence in the primary endpoint of stroke or TIA (8 versus 20.6 percent) for a relative risk reduction of 0.38 (95% CI ). No difference in the combined stroke and death rate at 30 days or 48 months (41 versus 44 percent); most of the deaths were due to coronary artery disease.

ACAS TRIAL —A SYMPTOMATIC C AROTID A THEROSCLEROSIS S TUDY This trial randomized 1662 patients with 60 to 99 percent stenosis, assessed with ultrasound and arteriogram, to CEA and aspirin (325 mg/day) or aspirin alone. the primary end point was cerebral infarction occurring in the distribution of the study artery or any stroke or death occurring in the perioperative period.

ACAS TRIAL —A SYMPTOMATIC C AROTID A THEROSCLEROSIS S TUDY After a median follow-up of 2.7 years, the following observations were reported: The incidence of ipsilateral stroke and any perioperative stroke or death rate was significantly lower in the surgical group than with aspirin alone (5 versus 11 percent) for a relative risk reduction of 0.53 (95% CI ).

ACAS TRIAL —A SYMPTOMATIC C AROTID A THEROSCLEROSIS S TUDY The study was not powered to determine gender differences. However, subgroup analysis suggested that CEA was less effective in women. Men had an absolute risk reduction of 8 percent; the absolute risk reduction in women was only 1.4 percent, perhaps due to a higher incidence of perioperative complications in women compared with men (3.6 versus 1.7 percent).

ACST TRIAL — A SYMPTOMATIC C AROTID S URGERY T RIAL is the largest multi-center study of asymptomatic carotid surgery that found benefit for CEA. From 1993 to 2003, the ACST randomly assigned 3120 patients with 60 percent or greater asymptomatic carotid stenosis by duplex ultrasound to immediate CEA or deferral of CEA until a definite indication occurred

ACST TRIAL — A SYMPTOMATIC C AROTID S URGERY T RIAL The main end points were perioperative mortality and morbidity (stroke and myocardial infarction) and nonperioperative stroke.

ACST TRIAL — A SYMPTOMATIC C AROTID S URGERY T RIAL At a mean of 3.4 years of follow-up the following results were reported : The CEA group had a perioperative risk of stroke or death of 3.1 percent within 30 days of surgery. The net five-year risk for all strokes or perioperative death in the CEA group was reduced by nearly half compared with the CEA deferral group (6.4 versus 11.8 percent). The benefit from CEA was significant for patients younger than 75 years of age.

ACST TRIAL — A SYMPTOMATIC C AROTID S URGERY T RIAL The benefit of CEA was significant for contralateral as well as ipsilateral carotid strokes. ( The benefit for ipsilateral and contralateral stroke reduction was independent of any history of contralateral occlusion or symptoms). The investigators speculated that collateral arterial flow via the Circle of Willis might be the mechanism for contralateral stroke risk reduction from ipsilateral CEA.

M ETA - ANALYSIS In ACAS, the ARR was 3.0 percent over 2.7 years. In ACST, the ARR was 3.1 percent over 3.4 years. Thus, the ARR in the two largest trials (ACAS and ACST) is about 3 percent over three years for the outcome of any stroke ; the corresponding number needed to treat (NNT) to prevent one stroke at three years is about 33.

CEA in asymptomatic patients should be considered a long-term investmentSignificant benefit for the population does not accrue until some time beyond two years after surgery. Delay to benefit The benefit of CEA appears to be greater for men than for women. Gender —

CEA should only be considered in asymptomatic patients at institutions where the perioperative stroke and death rate are less than 3 percent. Combined morbidity and mortality that exceed 3 percent for patients with asymptomatic carotid stenosis could eliminate the benefit gained from surgery Perioperative complications

C AROTID ENDARTERECTOMY IN SYMPTOMATIC PATIENTS North American Symptomatic Carotid Endarterctomy Trial (NASCET). European Carotid Surgery Trial. Veterans Affairs cooperative Trial(stopped prematurely ).

It is defined as focal ischemic symptoms that are referable to the appropriate carotid artery distribution, including one or more transient ischemic attacks or one or more minor (nondisabling) ischemic strokes. The occurrence of carotid symptom within previous 4 (NASCET) to 6 (ECST) months. It is defined as focal ischemic symptoms that are referable to the appropriate carotid artery distribution, including one or more transient ischemic attacks or one or more minor (nondisabling) ischemic strokes. The occurrence of carotid symptom within previous 4 (NASCET) to 6 (ECST) months.

Remote carotid symptom. Vertigo and syncope. Not Considered as symptomatic

NASCET-N ORTH A MERICAN S YMPTOMATIC C AROTID E NDARTERCTOMY T RIAL 659 patient with symptomatic carotid disease within 120 days before entry and who had stenosis of 70 to 99%. a lower Cumulative risk at 2 year of any epislatral stroke (9 %versus 26%). ARR was 17% & NNT was 6. The principal result of NASCET was significant benefit of CE in patient with 70 to 90% symptomatic stenosis.

NASCET-N ORTH A MERICAN S YMPTOMATIC C AROTID E NDARTERCTOMY T RIAL In the 50 to 69% group, there was a greater benefit from CE in men compared to women. For prevention of an ipsilateral stroke of any severity or for prevention of a disabling stroke, the NNT was 12 and 16 for men and 67 and 125 for women.

ECST - E UROPEAN C AROTID S URGERY T RIAL 2518 patients with symptomatic carotid stenosis were randomly assigned to medical therapy with ASA or to surgery : Patient with mild stenosis had little risk of ipisilatral ischemic stroke ; possible benefit of CEA was small and were outweighed by early risks. At 3 years, patient treated with CEA had significant reduction in the incidence of epislatral stroke (2.8 versus 16.8 with ASA alone).

ECST confirmed the result of the NASCET trial, demonstrating a benefit with CEA in symptomatic patient with sever ipsilatral carotid stenosis, although age and sex were important consideration in a decision about surgery.

Stenosis%recommendation 70-90% Effective for recently symptomatic (within previous 6 months) 50-69%Considered for patients with 50-69% symptomatic stenosis but the clinician Should consider additional clinical & angiographic variables. <50%Is not considered for symptomatic patient with < 50%stenosis Medical management is preferred to CE for symptomatic patients with <50% Use of cartoid endarterectomy in symptomatic patient

U SE OF CAROTID ENDARTERECTOMY IN ASYMPTOMATIC PATIENTS Stenosis (%) ICA angiographic Recommendation 60-99% It is reasonable to consider CE for patients between the ages 40 and 75 years and with asymptomatic stensois Of 60-99% if the patient has an expected five year life expectancy and if the surgical stroke or death frequency can be reliably documented to be <3%. The five year life expectancy is important since perioperative stroke pose an up front risk to the patient and the benefit from CE emerge only after a number of years

P ATIENT VARIABLES TO CONSIDER IN CAROTID ENDARTERECTOMY DECISION - MAKING Patient variablesrecommendation Symptomatic womenWomen with 50-69% symptomatic stenosis did not show clear benefit. Patient with hemispheric (TIA) attack or stroke Patient with hemispheric TIA or stroke had greater benefit than patient with retinal ischemic symptom. Patient treated within 2 weeks from last TIA or mild stroke derive greater benefit from CE. Progressing neurologic deficit No recommendation can be provided regarding the value of emergent CE.

R ADIOLOGIC FACTOR TO CONSIDER IN CAROTID ENDARTERECTOMY DECISION - MAKING Radiological factorRecommendation Contralateral occlusion in symptomatic patients Increased operative risk but persistent benefit. Contralateral occlusion in asymptomatic patients Erase the small benefit of CE in asymptomatic patient. Near occlusion in symptomatic patients Associated with trend toward benefit at two years but not associated with clear long term benefit.