Fundación Favaloro Carotid Artery Stenting in Asymptomatics Oscar A. Mendiz. MD.FACC.FSCAI Chief...
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Fundación Favaloro Carotid Artery Stenting in Asymptomatics Oscar A. Mendiz. MD.FACC.FSCAI Chief Interventional Cardiology SOLACI President August 2012
Fundacin Favaloro Carotid Artery Stenting in Asymptomatics
Oscar A. Mendiz. MD.FACC.FSCAI Chief Interventional Cardiology
SOLACI President August 2012
Slide 2
Fundacin Favaloro Conflictos de Interes Nombre: Oscar A. Mendiz
Medtronic: Proctor para CoreValve. Elli Lilly; Speacker
AstraZeneca: Advisory Board Sponsors para viajes a Congresos: Acher
(Cook), Angiocor (AGA), Cordis, BSCI, Cordis, Medikar, Sanofi.
2
Slide 3
Fundacin Favaloro Carotid Stenosis Asymptomatic: ~75%
Symptomatic: ~25% Normal Risk High Risk ~10%~25%~15%~50% Modified
from M Jaff, 2007 Carotid Artery Disease
Slide 4
Fundacin Favaloro Historical use only? NASCET Trial: events at
5 years in asymptomatic patients Barnett HJM, et al. JAMA.
2000;283:1429-1436 Note: 1-45% of the neuro events were NOT related
to the carotid lesion 2-Similar events in >60 and >70%
stenosis Although some data suggests you cannot use >80% as lone
criteria in asymptomatic pts, it is somehow arbitrary Only 15% were
receiving lipid lowering agents!!!!
Slide 5
Fundacin Favaloro Medical Treatment Improvements ACE-
Inhibitors vs. Placebo Cardiovascular Endpoints 0.5 1.0 2.0
Stroke166/6060 240/6064 CAD539/6060672/6064 CHF 154/6060 183/6064
CV death 307/6060 416/6064 Total death533/6060632/6064 0.70
(0.57-0.85) 0.80 (0.72-0.89) 0.84 (0.68-1.04) 0.74 (0.64-0.85) 0.84
(0.76-0.94) Number of Events/ Total Patients ACE-I Placebo Relative
Risk (95% CI) Blood Pressure Lowering Treatment Trialists
Collaboration Lancet, 2000; 355: 1955-64; HOPE, PART2; QUIET,
SCAT
Slide 6
Fundacin Favaloro Medical Treatment Improvements Statins:
Stroke Reduction in High Risk Ptes Mark C Bates. www.tctmd.com
Slide 7
Fundacin Favaloro Received Mxm after 2003 272 pts Medical
Treatment Improvements: Statins Carotid Intima Media Thickness
reduction with Atorvastatin Improvements on TCD Outcomes Mark C
Bates. www.tctmd.com 471 Patients with ACS Received Mx before 2003
199 pts HITS on TCD 3.7% HITS on TCD 12.6% Conclusion: With more
intensive Mx, regression of carotid plaque occurs in half our
patients; this has resulted in a marked decline of TCD microemboli
and clinical events among patients with ACS. J. David Spence,et
al.. More Intensive Medical Therapy has Reduced Microemboli and
Cardiovascular Eventsin Patients with Asymptomatic Carotid Stenosis
Abstract presented AHA San Diego 2009 Taylor AJ et al. Circulation
2002; 106: 2055-2060 Conclusion: Marked LDL reduction (
Slide 8
Fundacin Favaloro Annual TIA & Stroke rate reduction in
asymptomatic control arms of randomized trials
Slide 9
Fundacin Favaloro Ann L. Abbott. Stroke. published on-line Aug
20,2009 Caveats: 1. Different patient population (low risk) 2.
Improved outcomes with medical therapy have been under the
microscope of a clinical trial driven strict follow-up. Patients
are selected based on their willingness to comply with these strict
guidelines and investigators are admonished for failing to monitor
compliance Mark C Bates. www.tctmd.com
Slide 10
Fundacin Favaloro Improvements on CAS Outcomes over the time
Cremonesi Alberto. Linc 2012
Slide 11
Fundacin Favaloro Improvements on CAS Outcomes over the time:
Post Market registries Improvements on CAS Outcomes over the time:
Post Market registries Stroke & Death Patients (n = 6,320)
Incidence95% CI All Symptomatic Asymptomatic 3.6% 6.4% 3.2% 3.2-4.1
4.8-8.4 2.8,-3.7
Fundacin Favaloro High-Risk Asymptomatic Carotid Stenosis:
Ulceration on 3-D Ultrasound vs. Transcranial Doppler Microemboli
High-Risk Asymptomatic Carotid Stenosis: Ulceration on 3-D
Ultrasound vs. Transcranial Doppler Microemboli Prospective
analysis of 253 ACS ptes with >60% carotid stenosis 3-Year
Outcomes (incidence) > 3 Ulcers (4%) < 3 UlcersMicroemboli
(3%) NO Microemboli Stroke (%)18.21.720.01.7 Stroke or Death
(%)18.22.113.31.7 Conclusion: The presence of ulcers or microemboli
identify Ptes with Asymptomatic carotid stenosis who will benefit
from revascularization rather than optimal medical therapy alone.
Madani A, et al. Neurology 2011;77:744-750
Slide 23
Fundacin Favaloro Silent Cerebral Events in Asymptomatic
Carotid Stenosis Jayasooriya G, et al. J Vasc Surg. 2011
Jul;54(1):227-36 Aim: to examine the evidence for subclinical
microembolization and silent brain infarction in the prediction of
stroke in asymptomatic carotid stenosis using transcranial Doppler
(TCD), computed tomography (CT), and magnetic resonance imaging
(MRI). A specific pattern of silent CT infarctions was related to
future stroke risk (odds ratio [OR] = 4.6; confidence interval [CI]
= 3.0-7.2; P