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Презентация на тему Carotid Endarterectomy

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2. Stroke – 3rd cause of mortality 2nd
3. Incidence cases/year (per 1 million inhabitants):500 transient ischemic attacks2,400 strokes (75%: first ever strokes
4. History1875 – Gowers: first report
5. AimAmeliorate neurological symptomsPrevent stroke
6. Anatomy
8. PathologyAtherosclerosis 90%Usually in bifurcationIntracranial : Extracranial
10. Risk FactorsDiabetesSmokingHyperlipidemiaHypertensionGenetics
11. Completed StrokeEmbolic occlusion of critical arteryThrombosis of
12. T.I.A.Arterial Stenotic Theory ? CBFCerebral
13. Diagnosis –DuplexCT AngiographyMRAAngiography
14. ABCD-IAge (>60 yrs. = 1 point)Blood Pressure (>140/90 =
15. SurgerySymptomatic :Severe stenosis > 70%Good surgical risk patients with Moderate stenosis 50-70% and expected morbidity
18. Cross clamping
19. Carotid EndarterectomyStump pressure / Selective use of
22. COMPLICATIONSHematomaInfectionHypo/HypertensionIntracranial hemorrhageHyperperfusionCVA Re-stenosis
23. Morbidity / MortalityAsymptomatic 1-3%Symptomatic 3-5%
24. Cranial nerve Dysfunction:
25. ContraindicationsFresh CVASevere non rehabilitated strokeHigh cardiac riskShort life expectancy
26. Advanced age not a contraindication!!!
29. Surgery or Stent ?Safety ?Efficacy ?Cost Effectiveness ?Long Term Results ?
30. Common Practice – CEANumerous ReportsExcellent ResultsIndications widendContraindications Reduced
31. Missing Data for CASLate Stroke Rate ?Late Re-Stenosis Rate ?
32. Comparative Studies CEA VS. CASCRESTCARESSEVA-3SCAVATASSPACEARCHER
33. Does the high-risk patient for carotid
34. Carotid artery stenting is associated
35. CREST - ConclusionsDuring the periprocedural period, there
36. Indications for CASRe-stenosis after CEAPost Irradiation“Hostile Neck”Stiff Neck“High Risk” for CEA
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Stroke – 3rd cause of mortality 2nd Cardiovascular after MI mortality morbidity with socioeconomic burden for the patient, family & societyIntroduction

Carotid EndarterectomyNitecki SRambam Health Care Campus

Incidence cases/year (per 1 million inhabitants):500 transient ischemic attacks2,400 strokes (75%: first ever strokes

AimAmeliorate neurological symptomsPrevent stroke

PathologyAtherosclerosis 90%Usually in bifurcationIntracranial : Extracranial 33%

Risk FactorsDiabetesSmokingHyperlipidemiaHypertensionGenetics

Completed StrokeEmbolic occlusion of critical arteryThrombosis of end vessel (local or propagation)Sudden

T.I.A.Arterial Stenotic Theory ? CBFCerebral Embolic Theory ?10-15% of patients

Diagnosis –DuplexCT AngiographyMRAAngiography

ABCD-IAge (>60 yrs. = 1 point)Blood Pressure (>140/90 = 1 point)Clinucal Signs (hemisyndrome = 2;

SurgerySymptomatic :Severe stenosis > 70%Good surgical risk patients with Moderate stenosis 50-70% and expected morbidity

Carotid EndarterectomyStump pressure / Selective use of Javid ShuntEndarterectomy – longitudinal

COMPLICATIONSHematomaInfectionHypo/HypertensionIntracranial hemorrhageHyperperfusionCVA Re-stenosis

Morbidity / MortalityAsymptomatic 1-3%Symptomatic 3-5%

Cranial nerve Dysfunction: Vagus- Rec Laryngeal

ContraindicationsFresh CVASevere non rehabilitated strokeHigh cardiac riskShort life expectancy

Surgery or Stent ?Safety ?Efficacy ?Cost Effectiveness ?Long Term Results ?

Common Practice – CEANumerous ReportsExcellent ResultsIndications widendContraindications Reduced

Missing Data for CASLate Stroke Rate ?Late Re-Stenosis Rate ?

Comparative Studies CEA VS. CASCRESTCARESSEVA-3SCAVATASSPACEARCHER

Does the high-risk patient for carotid endarterectomy really exist? Pulli R,

Carotid artery stenting is associated with increased complications in octogenarians:

CREST - ConclusionsDuring the periprocedural period, there was a higher risk of

Indications for CASRe-stenosis after CEAPost Irradiation“Hostile Neck”Stiff Neck“High Risk” for CEA

Слайды презентации

Слайд 2 Stroke –
3rd cause of mortality
2nd Cardiovascular

after MI
mortality
morbidity with socioeconomic

burden for the patient, family & society

Introduction

Слайд 3
Incidence cases/year
(per 1 million inhabitants):

500 transient

ischemic attacks

2,400 strokes (75%: first ever strokes

Слайд 4 History
1875 – Gowers: first report

stroke/extracranial disease

1937 –

Monitz: Angiography for
carotid disease

1954 – Eastcot: first successful
operation for carotid stenosis

Слайд 5 Aim
Ameliorate neurological symptoms

Prevent stroke

Слайд 6 Anatomy

95% Aorta

Innominate Lt carotid Lt

Subclavian

Rt Subclavian Rt carotid

ICA ECA

Слайд 8 Pathology
Atherosclerosis 90%
Usually in bifurcation
Intracranial : Extracranial

33%

67%

Plaque growth: - Slow
- Rapid (Intraplaque hemorrhage)

Слайд 10 Risk Factors

Diabetes
Smoking
Hyperlipidemia
Hypertension
Genetics

Слайд 11 Completed Stroke
Embolic occlusion of critical artery

Thrombosis of end

Completed StrokeEmbolic occlusion of critical arteryThrombosis of end vessel (local or

vessel (local or propagation)

Sudden decrease in blood flow due

to proximal occlusion and no collaterals

Слайд 12 T.I.A.
Arterial Stenotic Theory ?
CBF

Cerebral

Embolic Theory ?
10-15% of patients have a

stroke within 3 months, with half occurring within 48 hours

Слайд 13 Diagnosis –
Duplex
CT Angiography
MRA
Angiography

Слайд 14 ABCD-I
Age (>60 yrs. = 1 point)
Blood Pressure (>140/90 = 1

ABCD-IAge (>60 yrs. = 1 point)Blood Pressure (>140/90 = 1 point)Clinucal Signs (hemisyndrome =

point)
Clinucal Signs (hemisyndrome = 2; speech =1)
Diabetes (DM=1; Duration:

>60=2)
I –Imaging (Duplex/CTA for Carotid Stenosis)
(MRI/MRP for minor stroke)
(Recurrent TIA)
Max -13 points. More than 7=8% stroke in 48 hrs.

Слайд 15 Surgery
Symptomatic :
Severe stenosis > 70%
Good surgical risk patients

with Moderate stenosis 50-70% and expected morbidity

:
- Controversial

Слайд 18 Cross clamping

Слайд 19 Carotid Endarterectomy
Stump pressure / Selective use of Javid

Shunt

Endarterectomy – longitudinal

eversion

Selective use of patch / Graft

Слайд 22 COMPLICATIONS
Hematoma
Infection
Hypo/Hypertension
Intracranial hemorrhage
Hyperperfusion
CVA
Re-stenosis

Слайд 23 Morbidity / Mortality
Asymptomatic 1-3%
Symptomatic 3-5%

Слайд 24
Cranial nerve Dysfunction:

Vagus- Rec Laryngeal

Sup Laryngeal
Hypoglossus
Glossopharyngeus

Слайд 25 Contraindications
Fresh CVA
Severe non rehabilitated stroke
High cardiac risk
Short life

expectancy

Слайд 26 Advanced age

not a contraindication!!!

Слайд 29 Surgery or Stent ?
Safety ?
Efficacy ?
Cost Effectiveness ?
Long

Term Results ?

Слайд 30 Common Practice – CEA
Numerous Reports
Excellent Results
Indications widend
Contraindications

Reduced

Слайд 31 Missing Data for CAS
Late Stroke Rate ?
Late Re-Stenosis

Rate ?

Слайд 32 Comparative Studies CEA VS. CAS
CREST
CARESS
EVA-3S
CAVATAS
SPACE
ARCHER

Слайд 33 Does the high-risk patient for carotid endarterectomy really

Does the high-risk patient for carotid endarterectomy really exist? Pulli

exist? Pulli R, Dorigo W, Barbanti E, Azas L, Pratesi

G, Innocenti AA, Pratesi C. Am J Surg. 2005 Jun;189(6):714-9

To date, definitely accepted criteria to identify "high-risk" patients for carotid endarterectomy (CEA) do not exist

CONCLUSIONS: Carotid endarterectomy is a safe procedure also in so-called high-risk subsets of patients. Severe comorbidites seem to affect only long-term survival.

Слайд 34 Carotid artery stenting is associated with increased complications

in octogenarians: 30-day stroke and death rates in the

CREST lead-in phase . Hobson RW 2nd et al. J Vasc Surg. 2004 Dec;40(6):1106-11

Interim results from the lead-in phase of CREST show that the periprocedural risk of stroke and death after CAS increases with age in the course of a credentialing registry. This effect is not mediated by potential confounding factors.
… care should be taken when CAS is performed in older patient populations.