Angioplasty.Org recently talked
with Dr. L. Nelson "Nick" Hopkins, Chairman of Neurosurgery,
Professor of Radiology, and Director of the Toshiba
Stroke Research Center at the University at Buffalo, State
University of New York. Truly one
of the pioneers in the treatment of stroke, as well as
the non-surgical therapies developed to treat both stroke and
carotid disease, Dr. Hopkins provides a unique perspective
into the growing area of cross-specialty and multidisciplinary
collaboration between and among medical specialities.
This three-part interview covers a range of topics:
- Part
One discusses the diagnosis and treatment of stroke;
- Part
Two deals with carotid artery disease;
- Part
Three discusses
how imaging
may impact future treatment, and how reimbursement
questions must be resolved for this field to move forward.
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L. Nelson
Hopkins, MD
University of Buffalo
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Q: How does this relate to the treatment and diagnosis
of carotid disease?
Dr. Hopkins: There are two issues with carotid disease. One is --
in patients who have severe carotid stenosis who have not yet had
a major stroke, our job is to try to identify which patients are
at risk for a stroke, identify the area of stenosis, how bad the
stenosis is, some of the characteristics of that stenosis, and, if
it fits the bill for a dangerous stenosis, then we need to fix that
before the patient has a stroke.
On the other hand, there are patients who
have carotid stenosis who progress to carotid occlusion and have
a stroke because of the
carotid occlusion. In that case, we have to identify whether or not
it’s feasible for us to reopen that occluded artery to reverse
the stroke. And there again we rely on CT perfusion and CT angiography
to help us determine whether or not it’s reasonable to try
to reopen an acutely occluded carotid artery, thus enabling us to
revascularize an ischemic brain and prevent or reverse a major stroke.
Q: One of the issues that patients
write in about, is that they’re
very confused about carotid artery stenosis, whether they’re
at risk, how to get it diagnosed, which type of doctor should they
go? Can you address that a bit?
Dr. Hopkins: First, it’s important for patients to know what
constitutes a degree of stenosis that warrants treatment. If the
patients are having neurologic symptoms, like mini-strokes, as a
result of the narrowing in their carotid artery, then any stenosis
greater than 50% should be fixed. If the patient is not having any
neurologic symptoms then, if the degree of stenosis is over 60% and
if the patient is an otherwise relatively healthy individual with
a reasonable life expectancy, then that’s a patient where revascularizing
or repairing that carotid artery makes sense, according to major
studies that have been carried out.
There are now, at this point in time, two
FDA-approved treatments for the treatment of carotid stenosis.
One is surgery, or endarterectomy,
where an incision is made in the neck, the artery is opened up and
the plaque is peeled out, and then the artery is re-closed, circulation
is reestablished. That’s a good operation, it’s been
around for 55, 60 years, and the results are very good. It is a more
invasive procedure, it leaves a scar on your neck, and there are
other downsides of open surgery. Like, for example, if you’re
not in the best medical shape, if you have heart disease, then the
open surgery is considerably more of a stress on your system and
on your heart than is the alternative, which is carotid angioplasty
and stenting - where again the endovascular approach is used, employing
the vascular highway. A small stent is navigated up into the carotid
artery and then that stent is opened up and used to force the artery
open. We normally place some kind of protection device either above
or below when we’re putting in a stent, because when you do
put in a stent and then dilate it up afterwards with a balloon, you
can release debris. And so we try to put some kind of embolic protection
device up to capture any debris that might be released during the
procedure, as a way to reduce the risk of that procedure.
But in general, we just need to understand
there are these two options. One is less invasive approach, using
carotid angioplasty and stenting
and one is a more invasive approach using surgery. I personally have
been doing surgery now for well over 30 years, and I know it’s
a good operation, and I’ve learned over the years which patients
are generally better candidates for surgery. In our center, we’ve
done over 2,000 carotid stents as well. So we’re really beginning
to get a good feel for who is a better candidate for surgery, and
who’s a better candidate for stenting. And fortunately for
our patients, we’re finding that these two procedures are quite
complimentary -- that is to say the patients who are bad candidates
for surgery are usually good candidates for stents, and vice versa.
I think it’s critically important that
you get an unbiased opinion from somebody who either does both,
or somebody who has a
team where you have surgeons and interventionalists on the same team
or at least in the same institution who can get together and give
you an unbiased approach as to which is the best way to treat your
particular carotid artery narrowing.
Q: How does a patient determine whether
they’ll be evaluated
well? This goes back to the turf wars…what’s the model
that you’re using in Buffalo to overcome these turf issues?
Dr.
Hopkins: In our shop we’re very fortunate in that we don’t
have any turf issues, because our endovascular team is our neurosurgical
team. We are all trained in both disciplines, and so we’re
very lucky. If you’re in a situation where you have one group
doing one procedure and another group doing the other -- the most
common scenario is cardiologists doing the carotid stent and vascular
surgeons doing the surgery -- then you want to find a place where
the team is working together, and where you can get a unified approach
from the two disciplines. Hopefully the two disciplines get together
and look at your case and decide which is the best way to do it.
Short of that, you should make sure that
you get another opinion. If you get an opinion, say from a surgeon,
and he says “this
case has to be done with surgery”, you go get another opinion
from a cardiologist or somebody who does carotid stenting, like a
neurosurgeon, and you then can at least get an opinion from both
disciplines to help you decide which one makes more sense. If you’re
finding that one’s telling you one thing, and one’s telling
the other, you need to get another opinion until you find somebody
that breaks the tie for you.
Q: Or you should get on a plane to Millard Fillmore
Hospital in Buffalo!
Dr. Hopkins: Obviously, I think we are able
to do a great job because we do both, but there are lots of places
in the country where you
can get very, very good treatment by a good integrated team, and
I think that’s what you really want to do. Get to a place where
the team is reasonably well integrated and where you’re going
to get a good *unbiased* opinion as to what’s the best way
to treat your problem.
Q: Some patients write in that they’ve
had an ultrasound exam on their carotids and then have gotten a
CT or invasive angiogram
and the results are very different, either much worse or not as bad.
Dr.
Hopkins: You’re bringing up a very, very important point.
You should never, ever allow yourself to have major surgery on the
basis of one non-invasive test. I think that is just critical. If
you have an ultrasound that says you have an 80% stenosis, and you
have a surgeon who’s telling you that you need to have it fixed,
tell him you want another study and another opinion -- because you
will find a significant discrepancy between CT angiograms and MR
angiograms and real angiograms versus the ultrasound.
The carotid ultrasound is a great screening
tool and it is extremely operator-dependant. If you have a very
experienced operator who has
a really good track record, you can get very accurate results. But
there are many, many centers where, although it’s a great screening
tool, the accuracy is not comparable to that of a CT angiogram. We
find in our shop that CT angiogram is far more accurate than Doppler,
or ultrasound. MR angiogram is somewhere in-between, and diagnostic
angiogram with contrast and a catheter-based procedure is still probably
the gold standard.
So we tend to, in elderly patients who come
to us with carotid stenosis and an ultrasound, we’ll always order another less-invasive
procedure like a CTA or an MRA and, if there’s a discrepancy
between the two, then we’ll go to diagnostic angiogram, catheter-based
angiogram. In patients where we see a lot of disease and where we
think we need as much information as possible, we’re liable
to go to a diagnostic angiogram to better assess the patient’s
collateral circulation. So it just depends on the patient and the
patient’s own situation. But certainly never rely on ultrasound
alone to allow somebody to operate on your neck. That’s just
not a good thing to do.
(continue
to Part Three)
This interview was conducted by Burt Cohen of Angioplasty.Org. |
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