The debate about carotid revasc in symptomatic patients

GA Pelouze MD MScSt John’s hospital Perpignan France

What is the problem?

• NASCET, in 1991 brought the evidence that carotid endarterectomy is beneficial in some symptomatic patients

• The Benefit/Risk ratio of carotid revasc is depending on– The absolute risk of stroke for the individual

patient– The absolute risk of stroke or MI or death in the

facility where the revasc is performed

How to solve it?

• Doctors needs the best evaluation tools• Absolute risk of stroke for the individual patient:

http://www.stroke.ox.ac.uk/• Absolute risk of stroke or MI or death in the

facility where the revasc is performed: – is it available on the web site of your hospital?– If yes compute it– If no try to evaluate it by the morbi-mortality rate of

the team or the operator you chose or put it at 3%

What trends are affecting the risks computed and BTW the decision?

Risk of stroke• The BMT has largely improved

and there is still a potential especially about APA efficacy and treatment of hypertension

• Risk of stroke of other origins is now better evaluated and treated especially in case of comorbidities

• Some situations are still difficult as treatment of carotid artery stenosis in the aftermath of thrombolysis

Risk of revasc• Stroke is less and less frequent after CE

I mean less than 1% in experienced hands

• Stroke is less and less frequent in CAS and new approaches and semi covered stents are coming with a potential to reach the rate of emboli we observed in CE

• Revasc is of maximal benefit when performed early

• As CREST has shown MI even minor should be adressed by complete diagnosis and revasc pre or postoperatively.

What is the Best Medical Decision about carotid revasc in symptomatic patients?Improving BMT ASAP• Stop smoking• Antiplatelet must be efficient,

heparin could be useful• Statins should achieve the

goal of LDL cholesterol < 1g/l• Hypertension should be

treated with proof of efficacy on 24hours monitoring

• Comorbidities should be adressed

Improving revasc• It is not a junior surgery• When the MMR is not available

it should be computed at 3%• When decided revasc should

be done quickly (<1week and probably <48h)

• CAS should be carefully monitored as it is a recent procedure

• Coronary events should be adressed ASAP

About healthcare policies

• Symptomatic patients are the most prone to benefit of carotid revasc

• Resources should be directed priorily to these patients because revasc for asymptomatic patients is far more questionable

• Funding of trials to reevaluate the results of NASCET and ECST is key 25 years after

References

• http://www.nejm.org/doi/full/10.1056/NEJM199108153250701

• http://www.nejm.org/doi/full/10.1056/NEJMc1312990?q

• http://informahealthcare.com/doi/abs/10.1586/14779072.2014.893826?journalCode=erk uery=TOC

• Ferrero E, Ferri M, Viazzo A, et al. A retrospective study on early carotid endarterectomy within 48 hours after transient ischemic attack and stroke in evolution. Ann Vasc Surg 2014;28:227-38