Thrombectomies mécaniques: Nécessité d une prise en charge anesthésique Laquelle?

Transcription

1 Thrombectomies mécaniques: Nécessité d une prise en charge anesthésique Laquelle? Laurent Pierot Reims Collège de Pathologie Vasculaire, Paris, 16 mars 2016

2 Disclosures Consultant: Codman Covidien/EV3 Microvention Neuravi Sequent

3 Traitement endovasculaire de l AVC ischémique Zeumer H et al. AJNR Am J Neuroradiol : L année noire: 3 études négatives: IMS III, Synthesis, MR-Rescue 2015: Une pluie d études positives MR CLEAN, ESCAPE, Extend-IA, SWIFT-PRIME, REVASCAT, THRACE

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5 Sédation consciente/ Anesthésie Générale?

6 Sédation consciente: pros Réduction du délai avant ponction fémorale Evaluation neurologique pdt le traitement Pas d hypotension due à l induction AG Eviter la potentielle neurotoxicité des drogues Hospitalisation plus courte en Réa/USI

7 Sédation consciente: cons Temps de procédure allongée Augmentation des risques de la procédure (Perforation? Dissection?) Echecs de la procédure Inconfort du patient Inconfort de l opérateur

8 Prospective Single-center 36 patients AJNR Am J Neuroradiol, 2013; 34: TICI 2b % mrs<=2 61.1%

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10 12 US Stroke centers Retrospective GA: 428 patients (44%) CS: 552 patients (56%) GA CS p ICA terminus 25% 15% <0.01 NIHSS 17+/-5 16+/-6 <0.01

11 Abou-Chebl et al, Stroke 2010

12 Abou-Chebl et al, Stroke 2010

13 Predictors of Clinical and Angiographic Outcomes in Acute Stroke Treatment: Subgroup Analysis From the Star Study Pereira VM et al, ISC 2014 Predictors of good outcomes OR Age 0.93 Baseline NIHSS 0.87 Absence of Hemorrhage 5.01 Time to Treatment 0.62 Conscious sedation 4.83 Successful recanalization 3.37

14 LA GA p TICI>=2b 72.9% 73.6% 0.9 mrs<=2 52.6% 35.6% 0.01 sich 7.1% 11.2% 0.4 Death 23.1% 34.0% 0.1

15 Abou-Chebl et al, Stroke 2014

16 GA/CS: Meta-Analysis OR GA/CS 95% CI p Successful recanalization <0.01 Death <0.01 Good functional outcome* <0.01 sich Respiratory complications <0.01 * mrs <= 2 But NIHSS is higher in GA group. Brinjikji, AJNR 2015

17 IMS III: GA/CS All intubated (n=147) Routine intubation (n=76) Medically indicated intubation (n=71) Not intubated (n=269) NIHSS (median) TICI % 79.7% 72.9% 72.8% mrs <= % 40.8%* 19.7% 48.0%* In-hospital death 23.1% 13.2%** 33.8% 7.4%** SICH 8.2% 6.6% 9.9% 4.8% *p=0.12. **p=0.11. Abou-Chebl, Stroke 2015

18 MR CLEAN: GA/CS GA (N=79) CS (N=137) Age (years Median) Male (%) 59% 58% NIHSS Range NIHSS median/iqr Door to start EVT (min - mean) Procedural duration (min mean) Onset to last angiogram (min mean)

19 MR CLEAN: GA/CS Control (N=267) % mrs GA (N=79) to 2 3 to 6 Non-GA (n=137) OR: Non-GA/Control: 2.79 GA/Control: 1.09

20 Importance de la PA PA systo PA systo PA systo PA diasto PA diasto PA diasto max min variabilité max min variabilité P=0.02 P< P=0.002 P=0.07 P< P=0.08 Jagani et al, JNIS, Série rétrospective, monocentrique AG: 38 patients SC: 61 patients SC AG mmhg

21 Importance de la PA: induction mmhg 35% 32% 32% PA systo min induction P= PA diasto min induction P=0.14 SC AG 30% 25% 20% 15% 10% 5% 0% 11% Baisse PA systo >10 induction P=0.03 4% Baisse PA diasto >10 induction P=0.07 SC AG Jagani et al, JNIS, 2015

22 Variation PA / Evolution clinique mmhg mrs<=2 mrs> Variation max PA systo P=0.01 Variation max PA diasto P=0.30 Variation max PA moy P=0.03 Jagani et al, JNIS, 2015

23 PA / Evolution clinique Série retrospective, monocentrique 108 patients AVC territoire antérieur AG systématique PA enregistrée toutes les 5 mn Independent predictors for poor neurological outcome (mrs>2) Chute PA moy > 40% NIHSS Absence de recanalisation p Henden et al, Stroke, 2015

24 ESO-ESMINT-ESNR Recommendations The choice of anesthesia depends on the individual situation; independently of the method chosen, all efforts should be made to avoid thrombectomy delays (Grade C, Level 2b, KSU Grade C)

25 2015 AHA/ASA focused update of the 2013 guidelines Recommendation 16: It might be reasonable to favor conscious sedation over general anesthesia during endovascular therapy for acute ischemic stroke. However, the ultimate selection of anesthetic technique during endovascular therapy for acute ischemic stroke should be individualized on the basis of patient risk factors, tolerance of the procedure, and other clinical characteristics. Randomized trial data are needed. (Class IIb; Level of Evidence C). (New recommendation) Stroke, October 2015

26 CS/AG: Trials SIESTA (Sedation vs. Intubation for Endovascular Stroke TreAtment) (PI: S. Schönenberger) Monocentric (Germany), prospective, randomized Primary endpoint: 24hr ENI Enrollment: 100 patients (now 150 after interim analysis) Current status: 121 inclusions End of recruitment: expected April 2016 ANSTROKE (Sedation Versus General Anesthesia for Endovascular Therapy in Acute Stroke) (PI: A. Rentzos) Monocentric (Sweden), prospective, randomized Primary endpoint: 90d mrs Enrollment: 90 Current status: 69 GOLIATH (General Or Local Anaestesia in Intra Arterial Therapy) (PI: M. Rasmussen / C. Simonsen) Monocentric, (Denmark), prospective, randomized Primary endpoint: Growth of DWI lesion Enrollment: 128 Current status (19/11/2015): 40 inclusions (no conversion CS to GA)

27 CS/AG: Trials COMET (COnscious sedation versus general anesthesia for MEchanical Thrombectomy) Project submitted to French Health Ministry Multicenter (23 french INR centers), prospective, randomized Primary endpoint: 90d mrs Enrollment (not started): 340 (based on MR CLEAN results)

28 Conclusions Les données de la littérature sont plutôt en faveur de l utilisation de la sédation consciente. Mais aucune étude n a jusqu à présent étudié cette question de façon méthodologiquement satisfaisante. Des études centrées sur cette question sont nécessaires.

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30 Techniques for Endovascular Treatment of Acute Ischemic Stroke From Intra-Arterial Fibrinolytics to Stent-Retrievers Laurent Pierot, MD, PhD; Sébastien Soize, MD; Azzedine Benaissa, MD; Ajay K. Wakhloo, MD, PhD Stroke. 2015; 46: