1 / 14

Asymptomatic Carotid Surgery Trial ACST-2

Asymptomatic Carotid Surgery Trial ACST-2. Collaborators Meeting 2014 Pembroke College, Oxford Is recent coronary stenting a problem (or an opportunity ) for enrolling the patient in the trial? Valerio Tolva MD, PhD Istituto Auxologico Italiano IRCCS Deparment of Surgery

devi
Télécharger la présentation

Asymptomatic Carotid Surgery Trial ACST-2

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. AsymptomaticCarotidSurgery TrialACST-2 Collaborators Meeting 2014 Pembroke College, Oxford Isrecentcoronarystenting a problem (or an opportunity) for enrolling the patient in the trial? Valerio Tolva MD, PhD Istituto Auxologico Italiano IRCCS Deparment of Surgery VascularSurgery (Head: Renato Casana MD) Milan, Italy

  2. Handling a patient with recentcoronarystenting and carotidstenosisislike a sailing race: You can head straight forcing the upwind : with double therapyperform CAS You can run on a beamwind and thenupwind : stop double therapy and performCEA Crewshaveguidelines for the right approach to a race… can we create guidelinesusing the data of the Trial?

  3. “the prevalence of severe carotiddisease (>80%% stenosis of ICA) amongpatientsundergoingPercutaneousCoronary Intervention (PCI)/Open HeartSurgery (OHS) isestimated to be 6% to 12%.” “…optimal treatment of patients with concurrentcarotid and coronaryarterydiseaseremainsunresolveddespite >110 publicationsduring the last 30 years reporting results in 9,000 patients.” Overview of the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP), from Timaran et al. J VascSurg 2009

  4. Coronaryrevascularizationbefore non cardiacsurgeryisbelievedtodecrease the peri- and post-operative risk in selectedpatients Fleisher LA et al. ACC/AHA 2007 Guidelines on perioperativecardiovascularevaluation. J Am CollCardiol 2007 The frequency of major non cardiacsurgery in the yearafterDrugElutingStentplacementis >4-5% Berger et al. Pre-Operative DES in EVENT Registry. J AmCollCardiolIntv. 2010 Van Kuijk et al. Timing of non cardiacsurgeryaftercoronaryarterystenting. Am J Cardiol 2009

  5. UnprotectedProtected Do PCI/Open HeartSurgeryaffect the rate of Major AdverseCardiovascularEvents in patient with carotidarterystenosis? Shishehbor et al. JACC. 2013

  6. Dashed line: CAS without PCI Solid line: CAS with PCI Tomai et al. 2011. JACC:CardiovascInterv Do PCI affect the rate of Major AdverseCardiovascularEvents in patients with carotidarterystenosis?

  7. Why do weconsiderPercutaneousCoronaryIntervention a bias? CEA withoutDoubleAntiPlateletTherapy RELATED COMPLICATIONS: death, MI, stentthrombosis Van Kuijk et al. Am.J.Cardiol, 2009

  8. SuspensionofDoubleAntiPlateletTherapyafterPercutaneousCoronaryIntervention (PCI) isassociated with the risk of peri-operative Major AdverseCardiovascularEvents due to stentthrombosis Stentthrombosisis a multifactorialprocess Surfacecoating: DrugElutingStents (DES), Bare Metal Stents (BMS) Stentdiameter Stentlength Vessel diameter Left ventricularejectionfraction Metabolicsyndrome

  9. Stent-relateddecisionmaking: PCI with BMS: The European Society of Cardiology + ACC/AHA recommends DAPT for a minimum of 6 weeks after PCI PCI with DES: The European Society of Cardiology + ACC/AHA recommends DAPT for a minimum of 1 year Always consider the time interval in patients with coronary and carotid lesions Avoiding DES in patientsscheduled for carotid or aorticsurgery can save 6-9 months. The cardiovascular crew

  10. Why do weconsider PCI a bias? CEA withDoubleAntiPlateletTherapy RELATED COMPLICATIONS: Severe bleeding (life-threatening, requiring surgical intervention, transfusion)

  11. Bleeding and DoubleAntiPlateletTherapy Bleeding and hematoma of the neck are the leadingcauses of in-hospital morbidityaftercarotidsurgery Major AdverseCardiovascularEvents and bleeding are the mainpredictors for unplanned hospital readmissionwithin 30 days of CEA Ho KJ et al. Predictors and consequences of unplanned hospital readmission. J VascSurg 2014

  12. Enrollablecarotidstenosis Recent PCI (< 3 months) Is DAPT stillrunning? A decision-making flowchart? YES NO BMS DES Symptoms? Unstableinstrumentalfindings? Wait 9 months Wait 3 months from PCI ENROLL THE PATIENT CAS

  13. Keypoints • The cut off for enrolling the patientis 3 months. • In asymptomaticpatients, cardiac timing is the leadingpriorityregardingcarotidstenosis • Carotidendarterectomyis the bias for enrollmentif the patientistaking double therapy • As DES and BMS havedifferentsafetyperiods, a tailoredstenting in patients with tandem lesions (coronary and carotid) must be considered. • RecruitmentCenters with CathLab can enroll 6-12% of patientsafter PCI (30-60 pts/year) • Shouldwe look at thissubgroupor will the trial give the answers?

  14. Before making a mistake… …Join the Trial and choose the best route

More Related