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Printable Handouts
Navigable Slide Index
- Introduction
- Disclosures
- Benefit of carotid endarterectomy
- What about asymptomatic stenosis?
- Old data no longer pertain
- Long term results of CREST and ACT-1
- In-hospital stroke/death rates for asymptomatics
- Early and late outcomes with CAS in Medicare
- Risk of CAS vs. CEA from 21 registries
- Decline in stroke risk
- Real world risk with best medical therapy
- Severity of stenosis
- Asymptomatic carotid stenosis (ACS)
- Not a ticking time bomb
- Decline in Risk of ICA occlusion with IMT (1)
- Decline in Risk of ICA occlusion with IMT (2)
- Plaque burden predicted risk
- Causes of death after ICA occlusion
- Identifying who might benefit from intervention
- TCD microembolus detection
- Asymptomatic Carotid Emboli Study (ACES)
- Measurement of 2-D Plaque area
- Enormous dynamic range for total plaque area
- Carotid Plaque Area as predictor of events (1)
- Carotid Plaque Area as predictor of events (2)
- Plaque progression despite therapy doubles risk
- Paradigm change: treating arteries, not risk factors
- Intensive medical therapy (IMT)
- Rates of plaque progression/regression by year
- Rates of plaque progression in ACS patients
- Decline of microemboli with more IMT
- Kaplan-Meier survival free of stroke, death, MI
- Microemboli predict risk despite IMT
- 90% of patients are better off with IMT
- Decline in events in ACS with more IMT
- Treating arteries without measuring plaque?
- Final thought on IMT
- Conclusions
- Thank you
Topics Covered
- Benefit of carotid endarterectomy (CEA)
- Symptomatic & Asymptomatic carotid stenosis and their treatment
- Treatment of symptomatic severe stenosis with special features
- Identifying prospective benefit from intervention
- Carotid plaque area as predictor of events
- Treating arteries instead of risk factors
- Intensive medical therapy
Links
Series:
Categories:
Therapeutic Areas:
Talk Citation
Spence, J.D. (2017, December 31). Management of carotid stenosis [Video file]. In The Biomedical & Life Sciences Collection, Henry Stewart Talks. Retrieved November 15, 2024, from https://doi.org/10.69645/ECZR9160.Export Citation (RIS)
Publication History
Financial Disclosures
- Prof. J. David Spence has not informed HSTalks of any commercial/financial relationship that it is appropriate to disclose.
Other Talks in the Series: Stroke Prevention
Transcript
Please wait while the transcript is being prepared...
0:00
I'm David Spence. I'm a Professor of Neurology and Clinical Pharmacology
at the University of Western Ontario, in London, Canada;
And Director of the Stroke Prevention and Atherosclerosis Research Centre
at the Robarts Research Institute.
This talk is about Management of Carotid Stenosis.
0:18
Here are my disclosures,
none of which is relevant to this talk.
0:24
So, the benefit of carotid endarterectomy was first shown by
the North American Symptomatic Carotid Endarterectomy Trial,
the NASCET trial, run at our institute,
the Robarts Research Institute by my boss, Dr Henry Barnett,
and the Asymptomatic Carotid Artery Surgery trial run at Winston-Salem, by Jim Toole.
That's ancient history; the first NASCET paper
came out in the New England Journal for severe stenosis in 1991,
and the moderate stenosis paper came out in 1998,
ACAS came out in 1995,
so that's a long time ago.
However, the NASCET trials showed very clearly,
that for patients with symptomatic severe stenosis,
there was a huge benefit of endarterectomy;
And the number needed to treat to prevent one stroke in two years,
in patients with symptomatic stenosis, aged below 75, was 6,
the number needed to treat for those aged 75 and older was only 3,
and for moderate stenosis it was 15.
However, in asymptomatic carotid stenosis,
even in the bad old days of ACAS,
the risk of stroke was so low that the number needed to treat was
approximately 70 or 80 patients who would
have to undergo surgery in order to prevent 1 stroke in 2 years.
Those risks were predicated on a 3% surgical risk,
and historical medical therapy that was much less intensive than what we use now.
So, it was clear from NASCET that patients with
severe symptomatic carotid stenosis should have medical therapy and endarterectomy,
and in selected cases,
stenting might be appropriate.
So, patients with a high carotid bifurcation making surgery more difficult,
patients with previous irradiation and scarring,
patients with previous surgery and scarring,
patients with a high medical risk,
and younger patients, might be suitable for stenting.
What about asymptomatic stenosis?