Restenosis: CEA vs. CAS...Kogure 2002 No Shenkai Geka 6,7 % Metz R 2002 Vasc Endovasc Surg 7,4 %...
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SPITZE IN DER MEDIZIN. MENSCHLICH IN DER BEGEGNUNG. ukr.de Disclosures Dr. Kasprzak (grants, speaker fee, development) Cook, Gore, Vascutek, Bard, Medtronic, Maquet, UCB, Bentley Prof. Dr. P. M. Kasprzak Department of Vascular Surgery , Endovascular Surgery University Hospital Regensburg, Germany Restenosis: CEA vs. CAS
Transcript of Restenosis: CEA vs. CAS...Kogure 2002 No Shenkai Geka 6,7 % Metz R 2002 Vasc Endovasc Surg 7,4 %...
SPITZE IN DER MEDIZIN. MENSCHLICH IN DER BEGEGNUNG.
ukr.deDisclosures Dr. Kasprzak (grants, speaker fee, development)
Cook, Gore, Vascutek, Bard, Medtronic, Maquet, UCB, Bentley
Prof. Dr. P. M. Kasprzak
Department of Vascular Surgery ,
Endovascular Surgery
University Hospital Regensburg, Germany
Restenosis:
CEA vs. CAS
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ICA Restenosis – historic data (1)
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H. Denck (1991):
Die Rezidivstenosen nach
Carotisdesobliteration
Prof Dr.H.Wenck
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ukr.deRezidivstenosen im supraaortalen Abschnitt
Heiner Wenk, Bremen
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Chang J 2002 Vasc Endovasc Surg 3,3 % 6,7 %
5 Jahre 10 Jahre
Gable D 2003 Am J Surg 3 % (Stent)
Kogure 2002 No Shenkai Geka 6,7 %
Metz R 2002 Vasc Endovasc Surg 7,4 % (nach 1 Jahr)
Setacci C 2003 Charing Cross 5,1 % in Stent Restensis
Shawl F 2002 Curr Opin Cardiol 2,7% (Stent)
DGG QS 2001 www.gefaesschirurgie .de 2,2%
ICA Restenosis – historic data (2)
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CEA/Patch
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Eversion Endarterectomy (EEA)
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Universitätsklinikum Regensburg
carotid plaque and ulcer
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intimal hyperplasiaUniversitätsklinikum Regensburg
CEUS
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Compliance of the Carotid Arteries after Endarterectomy
Arterial Mid-Pressure 90mmHgDirect Suture Vein-Patch
EEA
Polyester-Patch PTFE-Patch
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Restenosis ( 70 %) after CAS
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OP
89
Stent
12
39 TEA 35 PTFE 15 vein
asymptomatic symptomatic
specific - unspecified
Universitätsklinikum Regensburg
70 17 14
patients with carotid restenosis
n = 101
4/1995-5/2009
68 ♂, 33 ♀,
66 Jahre (48-84)
EEA TEA Stent
39 53 9
after (n) Op spectrum (%)
EEA TEA Stent andere
84 10 3 3
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– CARESS (JVS 2005) n= 397, follow up 12 months
3,6% CEA vs. 6,3% CAS n.s.
– CAVATAS (Stroke 2005) n= 347, follow up 12 months
5,2% CEA vs. 18,5% CAS p<0,001
-- Sapphire 3 years: 5,4% CEA vs. 2,4% CAS n.s.
-- SPACE 2 years: 4,6% CEA vs. 10,7% CAS p<0,001
Restenosis
CEA vs. CAS
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Prospective randomised trial for symptomatic ICA Stenosis –
Stent vs. CEA
1999- 2002
66 ♂ 20 ♀Age 68,4 ± 7,9
43 Stent, 44 Operations
Operation: Regional anesthesia (Winnie-Block)
EEA (or TEA)
SEP (Stump pressure / Neurologic evaluation)
DSA
Stenting: LA
transfemoral access
6F sheath, Carotid-Wall-Stent (ICA-CCA)
no embolic protection
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– 84 Patients evaluated
– 3 Patients lost to follow up
– 23 von 87 Patienten deceased (13 CEA, 10 CAS)
– 61 Patients with clinical and Duplex follow up after 65 mth´s
Patients to be followed (n=87)
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– 84 Patients evaluated
– 3 Patients lost to follow up
– 23 von 87 Patienten deceased (13 CEA, 10 CAS)
– 61 Patients with clinical and Duplex follow up after 65 mth´s
Patients to be followed (n=87)
Contralateral Stenosis >70 %
•5/32 (15,6%, CAS) und 3/29 (10,3%, CEA)
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CAS (n=32) CEA (n=29)
Restenose ≤70%Neurologic
symptoms (Stroke)
8
1
1
Restenose >70%,
OcclusionNeurologic
symptoms (Stroke)
Neurologic
symptoms (TIA)
6 #
3
1
0
1
# p<0,05 vs. CEA
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Prevalence of >70% Restenosis after CEA vs CAS
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Relationship between 70% restenosis-stroke
• >70% restenosis after CEA -> stroke risk
• No association for CAS (97% of strokes in <70% stenosis)
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Restenosis
6 years
after TEA
with
Dacron Patch
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Ischemic
stroke
DSA 2002
Stent PTA
2002
MRA after
Stent explantation,
Endarterectomy,
local Lysis with
30.000 Urokinase and
bovine Patch
Stent occlusion (ACI,ACE,ACC) 2 years after StentPTA
Explantat
Thrombosed stenosis
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How to treat ?
1. Best Medical Treatment
2. Operation
3. Stent
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Statin medication reduces stroke
reduction of relative lipid volume
in carotid plaque
Yamada K. Cerebrovasc Dis 2009
sympt asympt
Kadoglou NP.J Vasc Surg 2009
aggressive lipid lowering
Russell DA. J Vasc Surg 2007
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Conclusion
• Symptomatic high grade restenoses are more frequent in patients
after CEA (Patch TEA?)
• Carotid restenosis after stent and EEA shows more often
intimal hyperplasia
• Peak systolic velocity (PSV) correlates with symptoms
after CEA not CAS
• CEUS helps to identify stenoses at risk of embolization.
• Statin medication improves clinical course.
Medical history, primary procedure and morphology of restenosis
determines BMT and operative or interventional therapy.
Universitätsklinikum Regensburg
