Predicting Stroke

8/7/2019 Predicting Stroke

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LN Hopkins, MD

Elad Levy, MD

Adnan Siddiqui, MD, PhD

CAS vs CEA: How Would I Approach itwithout a Regulatory Restriction?


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L. Nelson Nick Hopkins, MDI disclose the following financial relationship(s).

Research Grant: Toshiba Speaker/Honoraria, Ownership Interest,

Consultant/Advisory Board: Boston Scientific

Speaker/Honoraria: BARD, Cordis, SCAI

Speaker/Honoraria, Consultant/Advisory Board: Abbott

Consultant/Advisory Board: W. L. Gore

Ownership Interest, Consultant/Advisory Board, Other-Board Member: Micrus

Ownership Interest, Other-Board Member:AccessClosure

Ownership Interest: Valor Medical


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LN Hopkins, MD

Personal Experience

CEA > 2000

CAS > 2000

PI or Co PI or steering committee CREST, CARESS, ARCHeR, CAPTURE,

BEACH, CABANNA, CABERNET, SAPPHIRE,VIVA, Act 1, EMPIRE, ARMOUR


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Life expectancy 5+ years

Severe stenosis

Low GSM, hemorrhagic plaque(MRI),TCD activity MCA, ulcerative lesion

Progression of plaque burden

Evidence of flow restriction/poor perfusion Previous Cerebral Ischemia, ipsi or contralateral

Fully informed patient

No other more obvious source

Asymptomatic PatientsWhen Do We Treat?


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Risk Factor Analysis

High risk CEA

High risk CAS

Evolution in

Experience

Technology

Objective assessment of which procedure looks best foreach patient based on trial results and personalexperience

How to TreatCEA vs CAS


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Predicting Stroke

WHO IS AT

GREATEST RISK??


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Severity of StenosisRisk of Stroke

90-99% 26%

80-89% 18%

70-79% 12%

NASCET


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95% - ulcer = 21% 2yr

95% + ulcer = 73% 2yr

Severe Stenosis + UlcerSTROKE RISK

NASCET


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Intracranial Atherosclerotic Disease

+ Carotid Stenosis

NASCET

Risk of Stroke

Medical Treatment

85-89% Increase

(3 year risk)Ie.Poor Collateral


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Age

Elderly Pts at Highest Risk for Stroke

CEA and CAS

Greatest Benefit in Elderly


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Elderly Patients

NASCET

Risk of Stroke70-99% Sten

Absolute Risk Reduction

Age 75 29%


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Predicting Stroke

Some of the patients atgreatest risk for Stroke arealso at Increased Risk for

CEA


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NASCET / ACAS

CEA effectively reducesstroke risk in Highly

Selected Patients


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Who is at High Risk

for CEA??

CAS Not Yet Approved...

CEA is the ONLY Choice


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CEA is ContraindicatedMedical Comorbidity

Pre-op CABG Angina pectoris

CHF

Recent or evolving MI

Renal failure


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CEA is ContraindicatedSurgical Contraindications

Recurrent carotid stenosis Previous perilesional

- cervical surgery

Contralateral laryngeal palsy Tracheostomy

Post cervical XRT

Biller - Circ 98


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CEA is ContraindicatedAnatomical Contraindications

Lesion above C2

Lesion below clavicle No neck / high bifurcation

- Common Sense


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CEA is Higher Risk

Poor Collateral

Contralateral carotid occlusion

Severe tandem intracranialstenosis

Multivessel occclusion

NASCET I & II


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Neurologic Instability Recurrent CVA

Crescendo TIA

Stroke in evolution

Fluctuating neurologic deficit

Intralumnal thrombus

CEA risk - 14%Seiber, JNS


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62 Year Old Male, Asx Carotid Stenosis

Father died of stroke at age 60CEA or CAS ??

CAS Not YET Approved


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1. Sx (hot) lesion2. Elderly pts

3. Low GSM4. Pre dil without EP5. Tortuousity- perilesional6. Aortic Arch disease7. Multiple stents8. Duration Filter9. Concentric calcium

10.Renal Failure...

CAS Risk FactorsWHEN IS CAS High Risk


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Know who is high risk for CEA

Know who is high risk for stroke

Know who is high risk for CAS

Do what you would do for your Mom


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Thank You!


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Documents

Predicting Stroke