CVD CASEY

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Cerebrovascular Disease:

Cerebrovascular Disease LCDR Kevin Casey, MC, USN Oct 13, 2011

Historical perspective:

Historical perspective 1856: the first link between carotid disease and stroke made on post-mortem examination 1914: Dr. Hunt published the first report emphasizing the relationship b/t CAD and CVA, describing the relationship b/t cerebral sxs and carotid stenosis as “cerebral intermittent claudication ” 1927: first carotid angiogram performed, documenting the first case of cervical carotid stenosis 1951: Carrea et al described their experience with a pt with CAS; they resected the disease ICA and anastosed the ECA to the distal ICA.

Historical perspective:

Historical perspective 1953: First CEA performed; however it was not written up until 1959 1954: first published report of CEA with primary anastomosis for pt with TIAs and carotid stenosis From the late 1960’s to the early 1980’s, the incidence of stroke-related death decreased dramatically as number of CEA’s increased

Natural History:

Natural History 500K pts suffer a new CVA in the US each year 200K of these patients will die within one year Annual cost of stroke 28 billion dollars Prognosis depends on the presence or absence of sxs 6-12% annual risk of subsequent CVA following initial event

Terminology:

Terminology TIA RIND CVA Stroke in evolution Crescendo TIA

Pathology:

Pathology Atherosclerosis: carotid bifurcation is susceptible to development of plaque formation Carotid lesions localize in regions of low flow velocity and flow separation, rather than regions of high velocity. Plaque formation follows intimal injury.

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Risk Factors: HTN HLP DM CAD PVD FHx Tobacco Prior TIAs

Risk Factors:

Risk Factors

Other Pathologies:

Other Pathologies Fibromuscular Dysplasia: 4 types, with medial fibrodysplasia accounting for most common. Appears as a focal stenosis or multiple lesions with intervening aneurysmal outpouchings Aneurysms: always associated with HTN and usually secondary to atherosclerosis; can cause distal embolization and occasionally cause CN compression Takayasu’s arteritis : usually young females; end result is constriction of or aneurysmal formation in vessels secondary to marked fibrosis /thickening of vessel wall. Radiation Dissection Coils/Kinks

Diagnostic workup:

Diagnostic workup Carotid Duplex: accessible, noninvasive, inexpensive, accurate, reproducible Can evaluate plaque density and surface morphology Can evaluate occlusion with a 97% sensitivity and specificity in some studies Limitations: technician-dependent and cannot visualize the arch or great vessel origins, distal ICA or intracranial vessels

Other modalities:

Other modalities MRA CTA Angiogram

Surgical Intervention:

Surgical Intervention

Treatment options:

Treatment options Medical Management CEA Carotid Stenting

Medical management:

Medical management Aggressive control of HTN (130/80) Statin use (LDL <110) Diabetes control ( Hgb A1C <7) Tobacco cessation ASA daily

CEA: the perfect procedure:

CEA: the perfect procedure Timing Anesthesia Shunting

Complications:

Complications CVA/TIA CV Respiratory CN injury Patch infection

Complications:

Complications CVA/TIA (<3%) CV (8%) Respiratory (<1%) CN injury (up to 15%) Facial: 4% Glossopharyngeal : 0.5% RLN: 5% Hypoglossal: 7% Patch infection (1%); majority after 6 months following surgery

Carotid Stent: The CREST Trial:

Carotid Stent: The CREST Trial

Questions:

Questions 79 yo m presents with TIAs w sxs of R arm weakness and and expressive dysphasia. CDS demonstrates 80-99% stenosis of the R ICA and 50-69% of the L ICA. Plaques were of mixed consistency. He takes an ASA daily. Pt has well-controlled HTN but is otherwise healthy. Cardiac stress test neg. The best treatment is: L CEA followed by delayed R CEA Add plavix to his ASA regimen R CEA followed by delayed L CEA Simultaneous B CEA Urgent R CAS to improve cerebral blood flow and make L CEA safer

Questions:

Questions 79 yo m presents with TIAs w sxs of R arm weakness and and expressive dysphasia. CDS demonstrates 80-99% stenosis of the R ICA and 50-69% of the L ICA. Plaques were of mixed consistency. He takes an ASA daily. Pt has well-controlled HTN but is otherwise healthy. Cardiac stress test neg. The best treatment is: L CEA followed by delayed R CEA Add plavix to his ASA regimen R CEA followed by delayed L CEA Simultaneous B CEA Urgent R CAS to improve cerebral blood flow and make L CEA safer

Questions:

Questions Two hours after an uneventful CEA, a 75 yo male is dysphasic and unable to move his RUE. A shunt was used during the procedure. The pt awoke without deficit, which was his baseline. The most likely cause of these sxs is: Hyperperfusion syndrome Malfunction of the shunt during the procedure Intimal flap at the distal endpoint causing thrombus formation in the endarterectomized segment A tandem lesion in the carotid siphon Intracranial hemorrhage

Questions:

Questions Two hours after an uneventful CEA, a 75 yo male is dysphasic and unable to move his RUE. A shunt was used during the procedure. The pt awoke without deficit, which was his baseline. The most likely cause of these sxs is: Hyperperfusion syndrome Malfunction of the shunt during the procedure Intimal flap at the distal endpoint causing thrombus formation in the endarterectomized segment A tandem lesion in the carotid siphon Intracranial hemorrhage

Questions:

Questions The Asymptomatic Carotid Surgery Trial (ACST) results show a benefit from CEA for 70 yo pts with asx carotid artery stenosis >70% 70 yo pts with asx carotid artery stenosis >60% 70 yo pts with asx carotid artery stenosis >50% 80 yo pts with asx carotid artery stenosis >70% 80 yo pts with asx carotid artery stenosis >60%

Questions:

Questions The Asymptomatic Carotid Surgery Trial (ACST) results show a benefit from CEA for 70 yo pts with asx carotid artery stenosis >70% 70 yo pts with asx carotid artery stenosis >60% 70 yo pts with asx carotid artery stenosis >50% 80 yo pts with asx carotid artery stenosis >70% 80 yo pts with asx carotid artery stenosis >60%

Questions:

Questions A 74 yo m had a successful R CEA with patch repair 8 years ago. Immediate post-operative CDS demonstrated a widely patent repair. He now presents with a >80% right carotid bulb stenosis . The most likely etiology of this lesion is: Intimal hyperplasia Infection of the prosthetic patch with compression Recurrent atherosclerosis Subintimal hematoma with dissection Inflammatory arteritis related to statin medications

Questions:

Questions A 74 yo m had a successful R CEA with patch repair 8 years ago. Immediate post-operative CDS demonstrated a widely patent repair. He now presents with a >80% right carotid bulb stenosis . The most likely etiology of this lesion is: Intimal hyperplasia Infection of the prosthetic patch with compression Recurrent atherosclerosis Subintimal hematoma with dissection Inflammatory arteritis related to statin medications

Questions:

Questions A 70 yo male is R dominant and has a left carotid bruit on PE. He has no history of ocular or cerebrovascular events. He has hypercholesterolemia and well controlled HTN. A CDS reveals B ICA stenosis of 80-99%. The best mgmt would be: Medical mgmt unless the pt develops focal neurologic sxs L CEA followed by delayed R CEA R CEA followed by delayed L CEA Simultaneous bilateral CEA B open cell carotid artery stents

Questions:

Questions A 70 yo male is R dominant and has a left carotid bruit on PE. He has no history of ocular or cerebrovascular events. He has hypercholesterolemia and well controlled HTN. A CDS reveals B ICA stenosis of 80-99%. The best mgmt would be: Medical mgmt unless the pt develops focal neurologic sxs L CEA followed by delayed R CEA R CEA followed by delayed L CEA Simultaneous bilateral CEA B open cell carotid artery stents

Questions:

Questions CEA is most beneficial for a (n) 60 yo male with a sx 70% carotid stenosis 70 yo male with an asx 95% carotid stenosis 60 yo female with a sx 70% carotid stenosis 55 yo female with an asx 90% carotid stenosis 85 yo female with an asx 90% carotid stenosis

Questions:

Questions CEA is most beneficial for a (n) 60 yo male with a sx 70% carotid stenosis 70 yo male with an asx 95% carotid stenosis 60 yo female with a sx 70% carotid stenosis 55 yo female with an asx 90% carotid stenosis 85 yo female with an asx 90% carotid stenosis

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