Transcript Asymptomatic Carotid Surgery Trial ACST-2

Asymptomatic Carotid Surgery Trial
ACST-2
Collaborators Meeting 2014
Pembroke College,
Oxford
Is recent coronary stenting a problem (or
an opportunity) for enrolling the patient
in the trial?
Valerio Tolva MD, PhD
Istituto Auxologico Italiano IRCCS
Deparment of Surgery
Vascular Surgery
(Head: Renato Casana MD)
Milan, Italy
Handling a patient with recent coronary stenting and carotid stenosis is like a sailing
race:
• You can head straight forcing the upwind : with double therapy perform CAS
• You can run on a beam wind and then upwind : stop double therapy and perform
CEA
Crews have guidelines for the right approach to a race…
can we create guidelines using the data of the Trial?
“the prevalence of severe carotid disease (>80%% stenosis of
ICA) among patients undergoing Percutaneous Coronary
Intervention (PCI)/Open Heart Surgery (OHS) is estimated to be
6% to 12%.”
“…optimal treatment of patients with concurrent carotid and
coronary artery disease remains unresolved despite >110
publications during the last 30 years reporting results in 9,000
patients.”
Overview of the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP), from Timaran et
al. J Vasc Surg 2009
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Coronary revascularization before non cardiac surgery is
believed to decrease the peri- and post-operative risk in
selected patients
Fleisher LA et al. ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation. J Am Coll Cardiol 2007
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The frequency of major non cardiac surgery in the year
after Drug Eluting Stent placement is >4-5%
Berger et al. Pre-Operative DES in EVENT Registry. J Am Coll Cardiol Intv. 2010
Van Kuijk et al. Timing of non cardiac surgery after coronary artery stenting. Am J Cardiol 2009
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Do PCI/Open Heart Surgery affect the rate of Major Adverse Cardiovascular
Events in patient with carotid artery stenosis?
Unprotected
Protected
Shishehbor et al.
JACC. 2013
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Do PCI affect the rate of Major Adverse Cardiovascular Events in
patients with carotid artery stenosis?
Dashed line: CAS without PCI
Solid line: CAS with PCI
Tomai et al.
2011. JACC:Cardiovasc Interv
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Why do we consider Percutaneous Coronary Intervention a bias?
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CEA without Double AntiPlatelet Therapy
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RELATED COMPLICATIONS: death, MI, stent thrombosis
Van Kuijk et al. Am.J.Cardiol, 2009
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Suspension of Double AntiPlatelet Therapy after Percutaneous
Coronary Intervention (PCI) is associated with the risk of perioperative Major Adverse Cardiovascular Events due to stent
thrombosis
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Stent thrombosis is a multifactorial process
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Surface coating: Drug Eluting Stents (DES), Bare Metal Stents (BMS)
Stent diameter
Stent length
Vessel diameter
Left ventricular ejection fraction
Metabolic syndrome
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Stent-related decision making:
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PCI with BMS:
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PCI with DES:
The European Society of Cardiology + ACC/AHA
recommends DAPT for a minimum of 6 weeks after PCI
The European Society of Cardiology + ACC/AHA
recommends DAPT for a minimum of 1 year
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Always consider the time interval in patients with coronary and carotid
lesions
Avoiding DES in patients scheduled for carotid or aortic surgery can
save 6-9 months.
The
cardiovascular
crew
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Why do we consider PCI a bias?
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CEA with Double AntiPlatelet Therapy
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RELATED COMPLICATIONS: Severe bleeding (life-threatening, requiring surgical
intervention, transfusion)
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Bleeding and Double AntiPlatelet Therapy
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Bleeding and hematoma of the neck are the leading causes of in-hospital
morbidity after carotid surgery
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Major Adverse Cardiovascular Events and bleeding are the main predictors for
unplanned hospital readmission within 30 days of CEA
Ho KJ et al. Predictors and consequences of unplanned hospital readmission. J Vasc Surg 2014
A decision-making flowchart?
Enrollable carotid stenosis
Recent PCI (< 3 months)
Is DAPT still running?
YES
NO
BMS
DES
Symptoms?
Unstable instrumental findings?
CAS
Wait 9 months
ENROLL THE PATIENT
Wait 3 months from PCI
Key points
• The cut off for enrolling the patient is 3 months.
• In asymptomatic patients, cardiac timing is the leading priority
regarding carotid stenosis
• Carotid endarterectomy is the bias for enrollment if the patient is
taking double therapy
• As DES and BMS have different safety periods, a tailored stenting in
patients with tandem lesions (coronary and carotid) must be
considered.
• Recruitment Centers with CathLab can enroll 6-12% of patients after
PCI (30-60 pts/year)
Should we look at this subgroup or will the trial give the answers?
Before making a mistake…
…Join the Trial and choose the best route