頸動脈狹窄的rct結果解讀

1、頸動脈狹窄的RCT結果解讀,樊雪強 葉志東 劉鵬中日友好醫(yī)院心血管外科,Carotid stenosis is present in 75% of men and 62% of women >65 years O'Leary DH, Polak JF, Kronmal RA

2、, et al. Stroke 1992; 23: 1752-60 According to the American Heart Association and American Stroke Association 170,000 CEA are performed annually in the USA The risk of developing stroke within 90 days of a transien

3、t ischemie event (TIA) is 10.5 %.The mortality rate of Cardiovascular and Cerebrovascular disease was NO 1 in 2008. Johnston SC, Gress DR, Browner WS, Sidney S. JAMA 2000;284:2901 -6.

4、 WoIfPA, D'Agostino RB, Kannel WB, et al. JAMA 1988;259:1025-9.,The Importance of the Carotid Artery Disease,History of Carotid SurgeryCarotid Angiogarphy 1927,Egas Moniz,Histo

5、ry of Carotid SurgeryExtracranial artery disease – Intracranial lesion,,,,,,,,James Hunt 1914,Miller Fisher 1951,,History of Carotid SurgeryCarotid Endarterectomy,Famous clinical trials for CEA,Indications of CEA for s

6、ymptomatic patients (NASCET, ECST),ischemic cerebral symptomsTIAamaurosis fugaxminor stroke ICA stenosis > 50%periprocedural stroke and death rate <6%,North American Symptomatic Carotid Endarterectomy Tri

7、al (NASCET),In 659 patients with a prior nondisabling stroke or TIA associated with a carotid stenosis of 70 to 99 percent, carotid endarterectomy significantly reduced the incidence of a major stroke or death at two yea

8、rs (p<0.01).,North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1991; 325:445.,Benefit of carotid endarterectomy after recent cerebral ischemic episode,The NASCET trial included 659 pa

9、tients with a recent transient ischemic attack or nondisabling stroke and a 70 to 99 percent carotid stenosis who were randomized to medical therapy or carotid endarterectomy. After a two year follow-up, the cumulative r

10、isk of any ipsilateral stroke was lower in those who underwent surgery compared to the medical group (9 versus 26 percent, p<0.001).,North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med

11、1991; 325:445.,Early CEA is associated with improved outcomes,,CEA is likely to be of greatest benefit if performed within two weeks of the last neurologic event in patients with 70 percent or greater carotid stenosis.,R

12、othwell, PM, Eliasziw, M, Gutnikov, SA, et al, Lancet 2004; 363:915.,European Carotid Surgery Trial,European Carotid Surgery Trialists' Collaborative Group. Lancet 1998; 351:1379.,Among 588 patients with a symptomati

13、c 80 to 99 percent carotid stenosis, carotid endarterectomy reduced the incidence of a major stroke (p<0.001).,Indications of CEA for asymptomatic patients (ACAS, ACST),carotid stenosis >60%additional risk facto

14、rs: contralateral occlusion,incomplete circulars - arteriosus Willisii, exhausted reserve capacityrapid progression of stenosisbefore major operation,periprocedural stroke and death rate<3%,ACAS trial,1662 as

15、ymptomatic ICA stenosisThe incidence of ipsilateral stroke and any perioperative stroke or death rate was significantly lower in the surgical group than with aspirin alone (5 versus 11 percent) for a relative risk redu

16、ction of 0.53 (95% CI 0.22-0.72).Subgroup analysis suggested that CEA was less effective in women. Men had an absolute risk reduction of 8% but in women was only 1.4%,ACST trial,3120 patients with 60 percent or gre

17、ater asymptomatic carotid stenosisThe CEA group had a perioperative risk of stroke or death of 3.1 percent within 30 days of surgery. The five-year risk for all strokes or perioperative death in the CEA group was red

18、uced by nearly half compared with the CEA deferral group (6.4 versus 11.8 percent ),The benefit from CEA was significant for patients younger than 75 years of age. The benefit of CEA was significant for contralateral a

19、s well as ipsilateral carotid strokes.,,Thrombendarterectomy versus Eversion EndarterectomyEVEREST Trial,,,,,,,,,,Primary Closure vs. Patch,Bond,R et al. J Vasc Surg 2004;40:1126-35,Synthetic Patch vs. Venous Patch,Syst

20、emic review of randomized controlled trials of patch angioplasty versus primary closure and different types of patch materials during carotid endarterectomy,Bond,R et al. J Vasc Surg 2004;40:1126-35,Locoregional v

21、ersus General anesthesia,Interpretation We have not shown a definite difference in outcomes between general and local anaesthesia for carotid surgery. The anaesthetist and surgeon, in consultation with the patient, shoul

22、d decide which anaesthetic technique to use on an individual basis.,GALA Trial 3526 Pts. Pimary outcome: GA:4,8% LA:4,5%,Lancet 2008;372:2132-42,Management of atherosclerotic carotid artery disease

23、: Clinical practice guidelines of the Society for Vascular Surgery J-Vasc-Surg.2008;48(2):480-6,,,The development of Carotid angioplasty and stenting (CAS),Effect of carotid artery stenting,Some completed and ongoing ran

24、domized clinical trials,,,,The last and biggest RCT for CEA and CAS,,,Conclusion:,EVA-3S- patients with symptomatic, the rates of death and stroke at 1 and 6 months were lower with endarterectomy than with stenting. CRE

25、ST- higher risk of stroke with stenting and MI with CEA,However, something will be happened like this:,In Stent Restenosis,In Stent Restenosis,,,Re PTA ??,Interposition ??,Restenosis on Carotid,,,,,Thanks for your atten