Should we continue to perform Carotid Endarterectomy?

2014 Annual Society for Vascular Ultrasound Conference

August 7, 2014Lake Buena Vista, Florida

Steven Leers MD, RVT, FSVU

Question

• The first carotid endarterectomy (CEA) was performed in– 1890– 1910– 1930– 1950– 1970

Answer

• The first carotid endarterectomy (CEA) was performed in– 1890– 1910– 1930– 1950– 1970

C. Miller Fisher MGH

• In the early 1950s, ischemic stroke attributed to vasospasm/MCA thrombosis

• Autopsy showed normal MCA• 1951 reviewed 8 stroke cases with angiogram

and autopsy findings• “One day surgeons may even devise a method

to remove the offending plaque and thereby prevent stroke”

Fisher CM, Occlusion of the internal carotid artery. Arch Neurol and Psychiatry 1951: 65:346-377

Beginnings

Eastcott HHG, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet 1954; 12: 994-996.

1954

“Mrs. A, a housewife, aged 66 was in bed Dec. 26, 1953, recovering from a cold when she had her first attack. She noticed that she could not use either her right arm or leg and that a film had come over her left eye. She tried to call her son but found she could not speak…Recovery was complete in a few minutes”

1954

“The carotid artery was punctured and three injections of contrast was made. The delayed filling of the internal carotid artery was confirmed and was shown to be due to an atheromatous lesion almost occluding the origin of the vessel.”

“At the time of her operation she had, in all 33 major attacks lasting from ten minutes to half an hour… Eight of these attacks occurred after her admission to hospital on April 9, 1954.”

1954

“On May 19 the patient was anaesthetized by Dr. C.A. Cheatle and her body temperature reduced to 82.4 degrees Fahrenheit by external cooling… The external carotid artery was ligated and the diseased segment of the artery (3cm long) was resected… Originally it was intended to insert a blood-vessel graft, but this proved to be unnecessary, a direct end-to-end anastamosis being performed.”

Eastcott HHG, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet 1954; 12: 994-996

1954

“On return to the ward the patient was gradually warmed; her body temperature had reached 98.6 twelve hours after the induction of anaesthesia… She made a satisfactory recovery…She was walking forty-eight hours after her operation and left hospital on June 2 (surgery 5/19).”

Eastcott HHG, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet 1954; 12: 994-996

Beginnings

• Originally described by Dr. Debakey although his series was not published until years later.

Debakey ME. Successful carotid endarterectomy for cerebrovasacular insufficiency. Nineteen -year follow-up. JAMA 1975: 233: 1083-85

CEA: Pathophysiology

• CEA never about revascularization, rather the removal of a dynamic disease process wherein dynamic plaque events either have already, or have the potential to cause thromboembolic stroke.

• Dr. Wesley Moore described the ominous implications and stroke potential of plaque ulceration.

Maddison FE, Moore WS. Ulcerated atheroma of the carotid artery; arteriographic appearance. Am J Roentgenol Radiium Ther Nuc Med. 1969: 107:530-534

CEA: Pathophysiology

Imparato and Wylie recognized subplaque hemorrhage as etiology of CVA

Imparato AM, Riles TS. The carotid bifurcation plaque: pathologic findings associated with crebral ischemia. Stroke, 1979: 10:238-45Lusby RJ, Stoney RJ, Wylie EF. Carotid plaque hemorrhage. Its role in production of cerebral ischemia. Arch Surg 1982: 117: 1479-88

Plaque morphology: CT, MR or high resolution ultrasound can predict patients likely to have symptoms

Nicolaides AN et al, Asymptomatic Internal carotid artery stenosis and cerebrovascular risk stratification, J Vasc Surg 2010: 52: 1486-96

CEA: Pathophysiology

• Still high correlation of symptoms with degree of stenosis.

• Intraplaque hemorrhage correlates with degree of stenosis.

• Severity of stenosis remains primary indication for CEA

Symptomatic disease

• CEA clearly established as superior to best medical therapy in symptomatic >70% stenosis NASCET Collaborators, 1991

• CAS carries higher risk in elderly patients and early post-CVA patients

Rantner, JVS 2012 Jim, JVS 2012

Medical Management of Carotid Disease

Modern antithrombotic and statin therapy has relegated surgery to Symptomatic patients onlySurgery for the asymptomatic lesion is inferior to statin therapy in this complex meta-analysis

Abbott, Stroke 2009

• Studies NOT corrected for threshold level of stenosis (not surgical lesions in the first place)

• Second Manifestations of ARTerial disease (SMART); less than 50% “surgical lesions”

• Oxford Vascular Study: 0.34%/year stroke rate– In subgroup of “surgical lesions” 3/32 (10%) had

CVA

Asymptomatic Disease: Natural History

• Schillinger, Vienna– >1000 patients followed with duplex scan– 10% progressed over 7 months– 2X stroke rate with progression– 70% of cohort on statins! Sabeti, Stroke 2007

• ACSRS (Asymptomatic Carotid Stenosis Risk of Stroke)– >1000 patients with moderate/severe stenosis– Stroke increased with degree of stenosis– 10% CVA rate at 3 years in severe lesions Nicolaides, Eur Jl Vasc Endovasc Surg 2005

REACH trial

• Reduction of Atherothrombosis for Continued Health registry– 3000 patients followed with >70% stenosis.– 1 year risk of stroke 6.5%– Published after Abbott’s meta-analysis

Aichner, Eur Jl Neur 2009

CEA safety/efficacy

• Large administrative databases regional and national have all demonstrated safety in a “real world” situation

Matsen et al, JVS 2006: California and MarylandSidawy et al, JVS 2009: SVS registryGoodney et al, JVS 2008: VSGNEKang et al, JVS 2009: NSQIP

2.2% overall stroke/death rate in 4000 CEA from 2005-2007

CAS: The Last Frontier?• Cost effectiveness: 9/10 studies show CEA

more cost-effective than CAS– Sternbergh et al, JVS 2012; Ochsner Clinic

• University of Michigan Medicare database study 2005-2007

• Cardiologists constitute 1/3 of operators but do ½ of procedures• CAS likely proceeded by cardiac cath, not TIA/CVA

– Berkowitz et al, Arch Intern Med 2011

CEA vs CAS• International Carotid Stenting Study (ICSS)– Composite endpoint stroke/death/MI– CAS group 8.5%, CEA 5.2%, highly significant

• CREST trial– 1200 patients randomized to CAS vs CEA• Stroke/death rate 4.8% for CAS, 2.6% for CEA• Symptomatic: 6% for CAS, 3.2% for CEA• 70 year age inflection point increases risk• Myocardial infarction more common in CEA

CEA vs CAS

– California hospital discharge data– Asymptomatic patients 2005-2009– Rigorous risk adjustment and propensity scoring– 6053 CAS, 36,524 CEA– CAS conferred a 2.49 odds ratio of stroke/death over CEA

Mayo Clinic Health Policy Research Unit Meta-analysis

• 2011 study of all randomized trial data• Relative stroke risk 1.8, death rate 2.53 for CAS

compared to CEA– Murad et al, JVS 2011

Conclusions• Strong history of scientific thought supports

idea of stroke prevention via carotid intervention

• CEA is safe and effective in symptomatic and high risk patients

• CEA is superior to best medical treatment even in asymptomatic patients

• CEA superior to CAS in ALL patient groups

THANKS!!