Impact of Contralateral Carotid or Vertebral Artery

Occlusion in Patients Undergoing CEA or CAS

Young-Wook Kim, DI Kim, YJ Park, GH Kim, KM Kim, GH Lee

Vascular Surgery, Neurology, Samsung Medical Center, Sungkyunkwan

University School of Medicine, Seoul, Korea, ywkim@skku.edu

Disclosure

• Financially nothing to disclosure

• To be published in J Vasc Surg

Updated SVS Guidelines for

Management of Extra-cranial Carotid Disease

CEA is recommended as the 1st-line treatment

• symptomatic carotid stenosis of 50%-99%

• asymptomatic carotid stenosis of 60%-99%.

(perioperative risk of stroke and death < 3%)

CAS is recommended

• symptomatic carotid stenosis of 50%-99%

at risk for CEA

Medical treatment

• asymptomatic patients at high risk for intervention

or with short (< 3 years) life expectancy

J Vasc Surg Sep. 2011

Contralateral Carotid Occlusion (CCO)

• Occurs in 6%-10% of patients undergoing

CEA

• Reduced collateral blood flow through the

circle of Willis: complete circle in 54%

CCO, contralateral carotid occlusion; CEA, carotid endarterectomy;

CAS, carotid artery stenting

• Increases flow amount and velocity of the

patent carotid or vertebral artery

• Often defined as a high risk factor for CEA

• Some authors advocated CAS rather than

CEA for patients with CCO

Relative Risk of Early Neurologic Eventsin Patients with CCO who Undergoing CEA

Relative risk of

stroke & death

NASCET: Surgical Results1

Meta-analysis pooled from

NASCET & ECST2

↑ 2.2 fold

↑ 2.2 fold

Post-hoc analysis of the

ACAS trial3Equivalent

(2.3% vs 2.2%)

1 Ferguson GG et al. Stroke 1999;30:1751-582 Rothwell PM et al. LANCET 2004; 363: 915-243 William H. Baker et al. Stroke 2000;31:2330-34

Author, y NoCCO

%

Neurologic event, %p

CCO(+) CCO(-)

Kretz, ’12 1212 6.7 1.2 1.5 NS

Goodney, ’12 6379 5.5 4.0 1.9 0.02

Bagaev, ’10 335 22.4 18.7 9.6 NS

Duncan, ’08 1609 6.0 5.2 1.3 0.01

Maatz, ’08 1960 8.2 5.6 2.1 0.002

Rockman, ’02 2420 14.0 3.0 2.1 NS

AbuRahma, ’00 399 12.3 2.0 5.4 NS

Early Neurologic Complications after CEA

According to the presence of CCO

CCO, contralateral carotid occlusion; CEA, carotid endarterectomy

NS, not significant

Early Neurologic Complications after CAS

According to the presence of CCO

Author, y NoCCO

%

Neurologic complication(%)p

CCO(+) CCO(-)

Keldahl, ’12 417 9.4 2.6 1.9 NS

Lago, ’11 479 13.2 0.0 4.3 NS

Mehta, ‘09 3137 6.1 6.0 4.5 NS

Sabeti, ’04 471 9.1 4.7 7.2 NS

CCO, contralateral carotid occlusion; CEA, carotid endarterectomy

NS, not significant

Recent Metaanalysis Results

Author PublicationSize of

cohortImpact of CCO

Faggioli

G. et al.

Jul. ’13

EJVES51,112

Increased cerebral events and death in

CEA, but not in CAS

Antoniou

GA et al.

Apr. ’13

JVS27,265

Increased perioperative and early

postoperative risk of stroke(OR, 1.65),

TIA(OR, 1.57) and death(OR, 1.76) in

CEA

Mercado

N et al.

Jan. ’13

JACC

13,993

CARE

registry

Not increased in-hospital death, non-

fatal MI, or non-fatal stroke in elective

CAS

Touze E

et al.

Oct. ’13

Stroke>70,000

Increased stroke and death after

CEA(OR, 1.56) but not in CAS

Purpose

• To determine the impact of CCO or

VAO on the development of early

symptomatic neurologic complication

(ESNC) following CEA or CAS

742 CEAs (in 678 pts) & 531 CASs (in 493 pts)

Total exclusions (n=120)

Analytic cohort: 698 CEAs & 455 CASs

CASs not using embolic

protective device (n=69)

Technical failure of CAS,

(n=7)

• A retrospective review of medical recordings &

angiographic data of patients who underwent CEA &

CAS in a single institution, 1995 - 2012

Methods

Combined CABG & CEA,

(n=44)

Diagnosis of CCO or VAO

MRA DSADuplex US CTA

Total occlusion of ICA or vertebral artery on Duplex US and

one other imaging study among CTA, MRA or DSA

Procedural details

CEA CAS

• General anesthesia

• Intraoperative intravenous

heparin

• Routine carotid shunt

• Standard CEA

• Primary or patch closure

• Postop. antiplatelet agent

• Local anesthesia

• Pre-procedural loading of

antiplatelet therapy

• Intraoperative intravenous

heparin

• Filter type EPD

• Post-procedural antiplatelet

agent

EPD, embolic protection device

Method• Patients were divided into 3 groups according to the

presence of CCO/ VAO

Group I Group II Group III

CCO Absent Present Absent

VAO Absent Present/absent Present

CCO, contralateral carotid occlusion; VAO, vertebral artery occlusion

Method• Compare early postop. outcomes of CEA/CAS

between groups

• Primary outcome

Early(<30d) symptomatic neurologic complications

(ESNC) including TIA & stroke

• Secondary outcome

Early(<30d) stroke

• Statistical analysis

Univariate, Chi square test / Fisher’s exact test,

simple logistic regression

Multivariate, multiple logistic regression

Frequency of CCO / VAO

Results

Group I Group II Group III

CEA (n=698) 545 (78%) 44 (6%) 109 (16%)

CAS (n=455) 336 (74%) 50 (11%) 69 (15%)

Patients Characteristics CEA patients (n=698)

Group I

n=545 (78%)

Group II

n=44 (6%)

Group III

n=109 (16%)P

Age, mean, y

range

67.1±7.5

44-85

66.7±6.8

47-80

69±7

53-86

0.036

Female 73(13%) 3(7%) 10(9%) 0.260

Preop. symptom

amaurosis

TIA

stoke

208(38%)

9(2%)

92(17%)

107(20%)

10(23%)

2(5%)

7(16%)

1(2%)

35(32%)

2(2%)

14(13%)

19(17%)

0.080

0.389

0.588

0.006

Older in group III and less frequent initial symptom

of stroke in group II

Patients Characteristics CAS patients (n=455)

Group I

(74%)

Group II

(11%)

Group III

(15%)

P

Age, mean, y

range

68.8±7.9

38-92

67±9.6

44-88

69.5±8.7

46-88

0.241

Female 48(14%) 4(8%) 13(19%) 0.249

Pre-CAS symptom

amaurosis

TIA

stoke

177(53%)

12(4%)

49(15%)

116(35%)

24(48%)

0

13(326%)

11(22%)

33(48%)

2(3%)

12(17%)

19(28%)

0.678

0.532

0.118

0.142

No significant difference between groups in CAS

patients

Comorbidity & Risk CEA patients (n=698)

Group I

(78%)

Group II

(6%)

Group III

(16%)

p

Hypertension 416(76) 31(71) 95(87) 0.022

CAD 197(36) 27(61) 48(44) 0.002

CKD 14(3) 2(5) 5(5) 0.327

Hyperlipidemia 357(66) 33(75) 65(57) 0.191

Smoking 312(57) 30(68) 56(51) 0.169

Atrial fibrillation 23(4) 2(5) 9(8) 0.166

CAD, coronary artery disease; CKD, chronic kidney disease

Hypertension more common in group III,

CAD more common in group II in CEA patients

Comorbidity & Risk CAS patients (n=455)

Group I

(74%)

Group II

(11%)

Group III

(15%)p

Hypertension 266(79) 36(72) 58(84) 0.284

CAD 90(27) 19(38) 26(38) 0.078

CKD 6(2) 0 3(4) 0.225

Hyperlipidemia 225(67) 36(72) 38(55) 0.101

Smoking 180(54) 31(62) 35(51) 0.435

Atrial fibrillation 16(5) 2(4) 6(9) 0.383

CAD, coronary artery disease; CKD, chronic kidney disease

No significant difference in comorbidity and risk

in CAS patients

Early symptomatic

neurologic Cx (ESNC)

CEA

(n=253)

CAS

(n=234) P

TIA 2(0.8%) 5(2.1%) .269

Stroke 6(2.4%) 16(6.8%) .018

Ipsilateral infarction

Non-ipsilateral infarction

Hemorrhagic

6(2.4%)

0

0

12(5.1%)

1(0.4%)

3(1.3%)

.107

.480

.110

Sum 8(3.2%) 21(9%) .007

Frequencies of ESNCs after CEA or CAS Symptomatic Patients (n=487, 42%)

Adjusted for age, hypertension and CAD

ESNC more frequent in patients presented with

stroke after in CAS

Early symptomatic

neurologic Cx (ESNC)

CEA

(n=445)

CAS

(n=221)P

TIA 7(1.6%) 1(0.5%) .281

Stroke 3(0.7%) 15(6.8%) <.001

Ipsilateral infarction

Non-ipsilateral infarction

Hemorrhagic

2(0.4%)

1(0.2%)

0

13(5.9%)

2(0.9%)

0

<.001

.257

Sum 10(2.2%) 16(7.2%) .002

Frequencies of ESNCs after CEA or CAS Asymptomatic Patients (n=666, 58%)

Adjusted for age, hypertension and CAD

ESNC more frequent in patients presented with

stroke after CAS compared to CEA

Univariate Risk Factor Analysis for

Early Symptomatic Neurologic Complications

VariablesCEA (n=18, 2.6%) CAS (n=37, 8.1%)

n(%) p n(%) p

Age ≥ 70y 10(56) NS 22(60) NS

Female 1(6) NS 4(11) NS

Hypertension

Diabetes

Hyperlipidemia

14(78)

7(39)

9(50)

NS

NS

NS

29(78)

20(54)

23(62)

NS

NS

NS

Smoking 8(44) NS 19(51) NS

Symptom

TIA

Stroke

8(44)

1(5)

7(40)

NS

NS

0.03

21(57)

8(22)

13(35)

NS

NS

NS

Group II 3(17) 0.044 4(11) NS

Group III 5(28) NS 6(16) NS

Multivariate Risk Factor Analysis for

Early Neurologic Complications (ESNC)

VariableCEA (n=18, 2.6%) CAS (n=37, 8.1%)

OR (95% C.I) p OR (95% C.I) p

Stroke 3.61 (1.29-10.13) 0.015 1.22 (0.60-2.50) NS

Group II 7.24 (1.73-30.37) 0.007 0.96 (0.32-2.91) NS

Group III 2.91 (0.95-8.92) NS 1.05 (0.41-2.67) NS

*Multiple logistic regression; adjusted for age, hypertension and CAD

Stroke and CCO are risk factors for ESNC in

CEA patients but not in CAS patients

Variable CEA (n=9, 1.3%) CAS (n=31, 6.8%)

OR (95% C.I) P OR (95% C.I) P

Strokea 7.10 (1.71-29.34) .007 1.41 (0.66-3.03) .375

Group IIb 5.18 (0.50-53.60) .167 0.57 (0.13-2.52) .459

Group IIIb 3.49 (0.78-15.51) .100 1.27 (0.49-3.28) .617

Multivariate Risk Factors Analysis for

Post-procedural Stroke Alone

a adjusted for hypertension and CAD b adjusted for hypertension, symptom status and CAD

Initial symptom of stroke was an only risk factor

for postop. stroke in CEA not in CAS

2.6%

6.8%

1.8%

4.6%

8.1% 8% 8% 8.7%

0

2

4

6

8

10

12

14

Overall Group II Group I Group III

ES

NC

(%

)

CEA CAS

P<.001 P <.001 P =N-SP =N-S

Frequencies of ESNCs after CEA / CAS

According to the Presence of the CCO or VAO

P =.044 P =N-S

Frequencies of Early Stroke after CEA / CAS

According to the Presence of CCO or VAO

1.3% 2.3%0.9%

2.8%

6.8%

4%

6.8%8.7%

0

2

4

6

8

10

12

14

Overall Group II Group I Group III

Ea

rly

str

ok

e ra

te (

%)

CEA CAS

P <.001 P <.001P =N-S P =N-S

P =N-SP =N-S

Conclusion

• CAS was followed by significantly higher frequencies

of ESNC(2.6% vs 8.1%) and stroke(1.3% vs 6.8%)

when compared to CEA

• CCO(group II) and initial symptom of stroke are

independent risk factors for ESNC in CEA

• In patients with CCO, the increased risk of ESNC after

CEA was still lower than that of CAS

• CCO was not a risk factor for stroke in patients

undergoing CEA

• Presence of VAO(unilateral or bilateral) in absence of

CCO was not a predictor of ESNC in patients

undergoing CEA or CAS

Thank you for your kind attention

Limitations

• Retrospective study design

• Did not considered completeness of circle of

Willis

• Inconsistent indications for CAS during the

study period

Contralateral Carotid Occlusion in CEA and CAS: A Single Centre Experience with Literature Review and Meta-analysis

Faggioli G et al. Eur J Vasc Endovasc Surg, 2013 ;46(1):10-20.

Outcomes CEA

P

CAS

PCCO (-) CCO (+) CCO (-) CCO (+)

Primary

any cerebral

event or death

2.9% 16.2% .001 8.7% 2.6% NS

Secondary

TIA 0.9% 5.4% .01 5.7% 2.6% NS

stroke 1.7% 8.1% .007 3.2% 0.0% NS

any cerebral

event

2.4% 13.5% .001 8.7% 2.6% NS

death 0.5% 2.7% .07 0.0% 0.0% NS

Odds of CCO to predict outcomes in CAS PatientsIn-hospital death, non-fatal MI, or non-fatal stroke

Endpoint less likely Endpoint more likely

Mercado N et al. Results from CARE registry, JACC , Jan. 2013

Propensity-matched

cohort

Adjusted for

• clinical demographic

• C-V risk factors

• prior neurologic Hx

Adjusted for

• clinical demographic

• C-V risk factors

Unadjusted

Relative Risk of Stroke after CEA or CAS

Touzé E et al. Stroke, Oct. 2013

Age>75/80 y

CCO

CAD

Diabetes

Male

High BP

Restenosis

PAD

Relative Risk

Side (Rt/Lt)

CAS CEA