j m cardon private hospital franciscaines nimes france
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Carotid surgerypast present future
J M CARDON
PRIVATE HOSPITAL FRANCISCAINES
NIMES FRANCE
Now in russia
First cause of mortality cardiac events: 683 170
Second stroke : 372 534
Third cancer: 293 602
Infografika 2012
The past
TCMM
1977 Easton JD
21,1%
And now
TCMMSérie Historique
1977 Easton 6,5 %
2,8 %
2,8%
2006 EVA 3S 3,9 %15000 cases in France
NASCET 1991
ACAS 1995
EVA 3 S 2006
INDICATIONS4 randomized study
Symptomatic stenosesNASCET 2885 patients 1987-1996ECST 3024 patients 1981-1994
Asymptomatic stenosesACAS1659 patients 1987-1993ACST3125 patients 1995-2003
INDICATIONS symptomatic stenoses
Sténoses > 70 %NASCET 2885 patients NEJM 1991ECST 3024 patients Lancet 1991
↓ R. Abs ↓ R. Relat NST / 1 stroke
strokeAvoided for1000 CEA
NASCET
17 % 65 % 6
170
ECST 8,5 %* 45 % 12 83
Symtomatic stenoses
Symptomatic stenoses
Sténoses 50-69 %NASCET 858 patients NEJM 1998ECST 646 patients Stroke 2003
↓ R. Abs ↓ R. Relat NST / 1 sroke
srokePrevented by
1000 CEA
NASCET
8,4% 26% 12
83
ECST 5,7% - - -
SYMPTOMATIC STENOSES
SOME SUBGROUPS HAVE
MORE BENEFIT FROM
SURGERY
Age > 75 (Nascet NST 3 vs 6)
stroke vs TIA
men vs women
central vs retineal
symptomatic stenoses
Résults of surgery according to delay from symptoms
No statiscal differrence in TCMM
<2 sem 2-4 sem 4-12 sem>12 sem
p
ECST 6,5% 6,4% 7,4% 8% 0,86
NASCET 7,1% 5,0% 6,5% 7,4% 0,64
Total 6,9% 5,7% 7,0% 7,8% 0,48
But the sooner is the better
Reduction of absolute risk of stroke and mortality at 5 years according to the delay of surgery
Rothwell : stroke 2004
INDICATIONS TIA
Stroke risk
7 days 10 %30 days 15 %
TIA is an emergency Angio MRI or scan in less than 24
h Duplex doppler Cardiac screening Hospitalisation if ABCD2 ≥ 3
INDICATIONS asymptomatic stenoses
Randomized controlled trials
CEA vs BMT ACAS 1995 Jama
ACST-1 2004 Lancet2010
Level 1 grade A evidence supporting CEA
In highly selective asymptomatic patents with a stenosis > 60 % CEA conferred a 50 % relative risk reduction of stroke at 5 years
asymptomatic stenoses
Sténoses > 60 %ACAS1662 patients JAMA 1995ACST3120 patients Lancet 2004
↓ R. Abs ↓ R. Relat NST / 1 AVC
strokeAvoided for1000 CEA
ACAS 5,9 % 53 % 19 53
ACST 5,4 % 45 % 18 54
ACTS – 1 : 10 years
asymptomatic stenoses
Subgroup analysis Degre of stenosis does not influence the results
better for men vs women (↓ r.a 8 / 1,4 %)
benefit arrive after 1 years
younger <75 years have more benefit than older
asymptomatic stenoseswhat about best medical treatment ?
USA 2005
Endartériectomie 135 701
92 % asymptomatique
With the use of statins in ACTS-1 The evidence of stroke fell strongly in the
medical arm
But it fall strongly as well is the CEA arm. So the difference is still highly significant
NO BENEFIT FROM CEA
Symptomatic Asymptomatique
< 50% NASCET < 60% NASCET
EASY INDICATION
STRONG INDICATION SYMPTOMATIC STENOSES >
75%
R. Abs R. Relat NST / 1 stroke
strokeAvoided by1000 CEA
NASCET
17 % 65 % 6
170
ECST 8,5% 45% 12 83
R. Abs R. Relat NST / 1 stroke
Stroke avoided by 1000
CEA
Sténoses Symptomatic
50-69 % NASCET
6,5% 29% 15
67
Sténoses Asymptomatic> 60 % NASCET
5,9% 53% 17
59
DISCUSSION
In summery : indications TIA are emergencies
Symptomatic patient have to be treated within 15 days
The degree of stenosis does not influence the stroke risk in asymptomatic patient with stenosis >60%
TCMM must be < 3% to operate asymptomatic patient
TECHNICAL EVOLUTION OF CEA
N TCMM Resténose ou occlusion
Ballotta1999
Eversion 169 0 0Patch 167 2,3% 4,9%
Green 2000
Eversion 107 0,9% 4,6%Patch 167 3% 4,7%
Everest Trial2000
Eversion 678 2,2% 3,6%EC 675 1,6% 9,2%
Cochrane DB2003
Eversion 1190 1,7% 2,5%EC ± patch 1173 2,6% 5,2%
EVERSION
Pour
LESS RESTENOSIS
NO CLINICAL BENEFIT
SURGEON CHOICE
Notre opinion
TECHNIC Eversion
G
TECHNIC Patch versus direct SUTURE
N TCMMperiop
TCMMFw-up
Resténose occlusion
Patch 936 2,3 % 13 % 4,3 %
Suture directe 833 3,7 % 20 % 13,7 %
NS S S
2009
2009
MAY REDUCE RESTENOSIS AND OCCLUSION RATE
REDUCE IPSILATERAL POST OP STROKE RATE
REDUCTION IN POST OP TCMM RATE
WHAT PATCH ?
Dacron Collagène vs PTFE
2004
CEREBRAL PROTECTION
2009
Avantage : hémodynamic and morphologic
data
PER-OP CONTROLDUPLEX SCAN
N Abnormalities FU(mois)
RESTENOSENormal vs minor
abnormal
Baker1994
316 19,6% 21,6 4,3% vs 17%
Ascher2004
650 2,3% - -
comparative study
angio No angio
N TCMM % N TCMM %
Roon
1992
535 1,3% 157 4,5%
Ricco
1996
112 0,9% 114 3,5%
per op Angiography
CONTROLE PER-OPERATOIREAngiographie per-op
Anesthésia
STROKE + DEATH +MI 30ème jour
GA 4,8 %
LA 4.5 %
Quality of life (1 month)
intervention time
ICU stay
hospital stay
3526 patients
NO différence
Héparine reversal
no major differrence between tecnics but eversion or systematic patch better than direct suture
No proof for shunting :never ,sometimes or always
Local or geneneral anesthesia are equivalent
Heparine reversal have no impact on stroke or MI risk
What about CAS ?
NEVER FOR SYMPTOMATIC PATIENT:Eva 3s , space , icss , crest:Risk x 3 comparing with CEA
Not for old > 80 years
Anatomy suitable for CAS
CAS vs CEA symptomatic stenose mortality or sroke at 30 days
Registres prospectifs NTCMM
Hobson (Crest) 99 12%2004
Stanziali (Pittsburgh) 87
9,2%2005
Gray (Capture) 594 7,9%2006
CAS RISK >80 YEARS
CAS and asymptomatic > 60%
Equivallence with CEA in crest
More than 100 CAS experience to get skills
Answer with ACST 2 study: work in progres
Progres in CAS
8F Transcervical Arterial Sheath 8F Venous Return Sheath
Large bore flow reversal circuit Flow controller with stop, HI and LO flow
Personal activity
CEA CAS
2010 88 20
2011 102 26
2012 86 43
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