Carotid revascularization in asymptomatic patients:
when should we do revascularization
Vipul Gupta
Neurointerventional Surgery/Interventional neuroradiologyMedanta The -Medicity
TRIALS
11% vs 5.1 %
Stroke 2013
Gain of 4.1% at 5 years and 4.6% at 10 years (13.4% vs 17.9%)
Against?•Medical therapy has improved significantly
Stroke 2009
In favour for intervention!
• Low complication rates of revascularization• Operator experience
• Technology
• Identification of high risk patients
Now -
1% risk
European society of vascular surgery, 2013Perirocedural risk (with in 30 days) stroke/MI/death – 1 %
Death or Any Stroke Rates Decrease for CAS over the Period of CREST Enrollment
Death or Major Stroke Rates in CASDecrease for Symptomatic Patients
How to select?Identify high risk patients
•Plaque morphology
•MES
•Progression
•Silent infarcts
•Hemodynamic (VMR, degree of stenosis)
• Consecutive patients
• > 60% stenosis on doppler
• TCD – 2 MES in 1 hour
• 3D US – Ulcer detection
Patients were on maximal medical therapy
Relative risk = 11.7
Relative risk = 8.6
• > 70 % stenosis on doppler
• MES assessment
• Echolucency grading
Intra-plaque hemorrhage
HR – 2-3 fold increase
Microembolic signals
• Stroke : 10-18.5 % vs 1 %
• Impaired vasomotor reactivity
• Cerebral blood flow patterns
JAMA 2000Breath holding index:<0.69 is impaired
Annual stroke risk - 13.9 % vs 4.1 %
Progression of stenosis
21.7 % experienced an ipsilateral stroke
• Silent cerebral infarcts
Miwa et al, > 8.5 fold higher risk
• Microemboli• Plaque morphology• Vasomotor reactivity• Silent infarcts • Progression
65-M, Hypertensive
Thank you