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London, United Kingdom 2013 14 Stroke prevention B 16:40 - 16:50 Importance of previous brain infarcts in patients with asymptomatic carotid stenosis & the impact of surgery in the Asymptomatic Carotid Surgery Trial (ACST-1) trial J. Streifler1, A. Halliday2, A . den Hartog3, S. Pan4, H. Pan5, R. Bulbulia6, D . Thomas7 University of Oxford, Oxford, UNITED KINGDOM1,University of Oxford, Oxford, UNIT-ED KINGDOM2, University of Utrecht, Utrecht, THE NETHERLANDS3, Clinical Trial Service Unit, Oxford, UNITED KINGDOM4, Clinical Trial Service Unit, Oxford, UNITED KINGDOM5, Clinical Trial Service Unit, Oxford, UNITED KINGDOM6, Imperial College, London, UNITED KINGDOM7 Background: Silent brain infarcts are common in patients at risk of stroke and are associat-ed with poor prognosis. Similar associations were claimed in asymptomatic carotid stenosis (ASCS) patients but the impact of previous infarction or symptoms on the beneficial effects of carotid endarterectomy (CEA) is unclear. Our aim was to evaluate the importance of prior brain infarcts (PBI) in ASCS patients in ACST-1 – a large trial with 10-year follow-up. Methods: 2333 of 3120 patients in ACST-1 had baseline brain imaging & were divided into 2 groups; 1331 with PBI (i.e. radiological evidence of an asymptomatic infarct or prior ischemic symptoms >6 months prior to randomization) (group 1) and 1002 with normal imaging and no prior symptoms (group 2). All trial patients were randomly allocated either immediate or de-ferred CEA. First stroke and vascular death were recorded during follow-up and in both groups we observed the impact of CEA. Results: The characteristics of patients with and without baseline brain imaging were broadly similar. Male gender and hypertension were somewhat commoner in group 1 while mean ipsi-lateral stenosis was slightly greater in group 2. More strokes were observed amongst those with brain infarcts before randomization (absolute risk increase ARI 5.8% 1.8-9.8, p=0.004); risk of stroke and vascular death (6.9% 1.9- 12.0 ARI, p=0.007) was also higher in this group. On multivariate analysis PBI was associated with greater risk of stroke (HR=1.51 95%CI:1.17-1.95) and with stroke or other vascular death (HR=1.30 95%CI:1.11-1.52). Benefits of CEA at 5 years appeared greater for group 1 patients (gain 4.9% p=0.005%) than for group 2 (gain at 5 years, 3.9% p=0.02%) though ACST-1 was not randomly comparing these. Conclusion: ASCS patients with PBI have higher stroke risk during long-term follow-up than those without PBI. The beneficial effect associated with allocation to immediate CEA was sim-ilar in both groups, but greater absolute benefits were seen amongst patients with prior brain infarcts Evidence of prior ischaemic events might help identify patients in whom carotid inter-vention Cerebrovasc Dis 2013; 35 (suppl 3)1-854 161 is particularly beneficial 16:30-18:00 Oral Session Room 9,10 Stroke prevention B Chairs: L. Kappelle, The Netherlands and A. Lindgren, Sweden 13 Stroke prevention B 16:30 - 16:40 Carotid artery stenting : is there an operator effect? A pooled analysis of individual pa-tient data from three randomised trials in the Carotid Stenting Trialists’ Collaboration (CSTC) D. Calvet1, J.L. Mas2, A. Algra3, J.P. Becquemin4, L.H. Bonati5, G. Fraedrich6, O. Jansen7, W.P. Mali8, P.A. Ringleb9, G. Chatellier10 Department of Neurology, Hôpital Sainte-Anne, Université Paris Descartes, INSERM UMR894, Paris, FRANCE1,Department of Neurology, Hôpital Sainte-Anne, Université Paris Descartes, INSERM UMR894, Paris, FRANCE2, Department of Neurology and Julius Centre for Health Sciences and Patient Care, University Medical Centre Utrecht, Utrecht, THE NETH-ERLANDS3, Department of Vascular Surgery, University Hospital Henri Mondor, Créteil, FRANCE4, Department of Neurology and Stroke Unit, University Hospital Basel,, Basel, SWITZERLAND5, Department of Vascular Surgery, Medical University, Innsbruck,, Innsbruck, AUSTRIA6, Department of Neuroradiology, UKS-H, Campus Kiel, Kiel, GERMANY7, Depart-ment of Radiology, University Medical Centre Utrecht, Utrecht, THE NETHERLANDS8, De-partment of Neurology, University Hospital Heidelberg, Heidelberg, GERMANY9, Clinical Research Unit, Hôpital Européen Georges Pompidou, Université René Descartes, Par-is, FRANCE10, Department of Brain Repair and Rehabilitation, Institute of Neurology, Univer-sity College London, London, UNITED KINGDOM11 Background Randomized clinical trials show higher risks of stroke or death within 30 days of treatment af-ter carotid artery stenting (CAS) compared to surgery for symptomatic carotid stenosis. To im-prove the risk–benefit profile of CAS, it is crucial to establish which factors are associated with a high risk of stroke after CAS. In this respect, we examined whether operator experience is as-sociated with the 30-day risk of stroke or death in the Carotid Stenting Trialists’ Collaboration (CSTC) database. Methods The CSTC is a pooled individual patient database including all the patients recruited in the three large European-based randomized trials of stenting versus endarterectomy for symptomat-ic carotid stenosis (EVA-3S, SPACE, and ICSS). Lifetime CAS experience, lifetime experience in stenting procedures excluding the carotid, and annual in-trial volume, divided into tertiles, were used to measure operator experience. The outcome event was the occurrence of any stroke or death within 30 days of the procedure. The analysis was done per-protocol. Results Among 1679 patients who underwent CAS, 130 (7.7%) had a stroke or death within 30 days of the procedure. The 30 day-risk of stroke or death did not differ according to operator lifetime CAS experience (p=0.8) or operator lifetime stenting experience excluding the carotid (p=0.7). By contrast, the 30-day risk of stroke or death was significantly higher in patients treated by lowest-volume (10.1%, age-adjusted RR =2.011.29-3.13) and intermediate-volume (8.4%, age-adjusted RR=1.68 1.06-2.66) operators compared with patients treated by highest-volume operators (5.1%). The 30-day risk of stroke or death did not differ in three successive periods of the trials (each including one third of patients). Conclusions Our data suggest that annual operator CAS volume rather than lifetime experience is a predictor of 30-day risk of stroke or death after CAS. Carotid stenting should only be performed by oper-ators with high annual procedure volume.


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