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Prospective Analysis of Carotid Stenting in High Risk Patients

Prospective Analysis of Carotid Stenting in High Risk Patients. Dae Chul Suh, MD Asan Medical Center University of Ulsan College of Medicine. Acknowledgement. Neuoradiology Sang Joon Kim, MD Choong Gon Choi, MD Deok Hee Lee, MD Ho Sung Kim, MD Ha Young Lee, MD Jee Won Park, MD

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Prospective Analysis of Carotid Stenting in High Risk Patients

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  1. Prospective Analysis of Carotid Stenting in High Risk Patients Dae Chul Suh, MD Asan Medical Center University of Ulsan College of Medicine

  2. Acknowledgement • Neuoradiology • Sang Joon Kim, MD • Choong Gon Choi, MD • Deok Hee Lee, MD • Ho Sung Kim, MD • Ha Young Lee, MD • Jee Won Park, MD • Jong Lim Kim, MD • Soonchan Park, MD Neurology Jong Sung Kim, MD Dong-Wha Kang, MD Jae YoungKoh, MD Sun Uck Kwon, MD Neurosurgery Seung-Chul Rhim, MD Byung-Duk Kwun, MD Jae Sung Ahn, MD Neuroangio-room Sun Moon Whang, RT Ok Kyun Lim, RT Jin Ho Yoon, RT Tae Ii kim, RT Jeong Suk Yoon, RN Eun Hye Kim, RN Yun Gyeong Jeong, BS Dankook University Kyunghwan Yoon, PhD Young Bae Ko, PhD Ulsan University Sang Wook Lee, PhD

  3. CREST Summary 2502 patients over a median 2.5 y FU 4y rates of the primary end point (CAS & CEA) 7.2% and 6.8% hazard ratio with stenting, 1.11 (95% confidence interval, 0.81 to 1.51; P = 0.51) no significant difference 4y rate of stroke or death 6.4% with CAS & 4.7% with CEA (hazard ratio, 1.50; P = 0.03) symptomatic patients 8.0% and 6.4% (hazard ratio, 1.37; P = 0.14) asymptomatic patients 4.5% and 2.7% (hazard ratio, 1.86; P = 0.07) (Periprocedural event) death (0.7% vs. 0.3%, P = 0.18) stroke (4.1% vs. 2.3%, P = 0.01) myocardial infarction (1.1% vs. 2.3%, P = 0.03) (After this period) Ipsilateral stroke with CAS and with CEA were similarly low (2.0% and 2.4%, respectively; P = 0.85)

  4. CREST is the largest RCT comparing CAS vs CEA * Trials stopped prematurely

  5. OperatorEligibility

  6. 4 Year Outcome Mas ,J.L. et al. Lancet Neurol. 2008

  7. Carotidstent & Embolic protection devices Acculink & Accunet systems Abbott Vascular Solutions SpiderFX RX ACCUNET™ Embolic Protection System FilterWire EZ™ PercuSurge RX ACCULINK™

  8. No significant difference in the estimated 4-year rates of the primary end point between CAS and CEA

  9. Carotid Stenting in Old Age AMC Result (309 stenting in 273 patients) Patients numbers Patients numbers Patients numbers ■ Ipsilateral event (+) ■ Ipsilateral event (-)

  10. KimHJ, et al AJNR 2010

  11. Peri-procedural Death & Stroke CAS CEA AHA Guideline 6.0% High Surgical Risk Standard Surgical Risk High Surgical Risk Standard Surgical Risk Brott TG., et al. NEJM 2010

  12. Further Considerations in Carotid stenting • Devices - EPD (embolic protective device) & stents • Antiplateletagents- Resistance to clopidogrel • Medication - for plaque stabilization • Procedural technique - experiences • Cranial nerve injury in CEA - Wound problem • Management of high risk factors • Important clue for outcome improvement

  13. High shear stress Low shear stress Park ST, et al. AJNR 2010

  14. Apical type Body type

  15. Extended Apical type lesion

  16. Extended Apical type lesion

  17. Park ST, et al. AJNR 2010

  18. 70/M Post CEA Pre

  19. 68/M

  20. AMC data • 309 stenting in 273 patients (2002 – 2009) • High risk (92%) • Symptomatic (81%) • 1m event rate • 4.8% ipsilateral stroke • 6.2% any stroke • 6.2% overall • 6m event rate • 0.4% ipsilateral stroke • 0.7% any stroke • 3.7% overall • ≤6m event rate • 5.1% ipsilateral stroke • 7.0% any stroke • 9.9% overall

  21. Apical vs body

  22. Stenting - not performed • 9 patients out of prospective study of 153patients • Tortuous vessels 3 • Less than 50% stenosis 3 • Decreased renal function 1 • Total occlusion 2

  23. 77/F

  24. Simultaneous Bilateral carotid stenting (36/273)

  25. Simultaneous Bilateral carotid stenting Liu S, et al. AJNR 2010

  26. Contralateral stenosis or occlusion Patients numbers Contralateral = Contralateral stenosis or occlusion

  27. AMC data • Retrospective 142 patients (2002 – 2006) • Prospective 131 patients (2007 – 2009)

  28. SAPPHIRE vs AMC SAPPHIRE 2000-2002 (n = 159) AMC 2002-2009 (n = 273) % Primary end point (death, stroke, or myocardial infarction at 30 days plus ipsilateral stroke or death from neurologic causes within 31 days to 1 yr)

  29. Conclusion • Overallevent rate in high risk patients of AMC • Any stroke 6.5% • Modification of cerebrovascular risk factors • After identification of risk factors • Stabilization of unstable plaque • High risk patients for stenting • Age, contralateral steno-occlusion, etc • Identification of risks • Body vs apical lesion type • Strategy to overcome the risk

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