VČASNÁ KAROTICKÁ ENDARTEREKTÓMIA NAŠE SKÚSENOSTI. Kuročka M., Beňo P., Rusňák M., Rusňák F. KCCH ÚVN SNP Ružomberok - FN
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1 VČASNÁ KAROTICKÁ ENDARTEREKTÓMIA NAŠE SKÚSENOSTI Kuročka M., Beňo P., Rusňák M., Rusňák F. KCCH ÚVN SNP Ružomberok - FN
2 ISCHEMICKÁ CMP Náhla porucha cirkulácie krvi v mozgu, vyvolávajúca nekrózu mozgového tkaniva s korešpondujúcim klinickým neurologickým deficitom 80 % z celkového počtu CMP 3. najčastejšia príčina smrti vo vyspelých krajinách Ročné riziko pri asymptomatických stenózach ACI 3-5% Ročné riziko pri symptomatických stenózach ACI 20-25% Kováčik, M. Význam karotickej endarterektómie v neurológii. Kapitoly modernej neurológie. 2013, 1-39
3 ETIOLÓGIA Makroangiopatia /postihnutie veľkých tepien/ - 20% - aterosklerotické % - neaterosklerotické /disekcia, fibromuskulárna dysplázia/ Mikroangiopathia Embolizácia zo srdca /mitrálna stenóza, fibrilácia predsieni/ % CMP z nezistenej príčiny Kanát, D. et al. Karotická endarterektómia v súbore našich pacientov s karotickou stenózou. Neurológia /3:
4 KLINICKÁ KLASIFIKÁCIA I. štádium - asymptomatická stenóza - skríning II. štádium - TIA - epizóda prechodnej neurologickej dysfunkcie spôsobenej fokálnou ischémiou, bez akútneho infarktu mozgového tkaniva, trvajúca niekoľko sekúnd, menej ako 1 hodinu - crescendo TIA - dve a viac epizód v priebehu 24 hod., s úplnou úpravou neurologického stavu po každej epizóde III. štádium - stroke in evolution - progresia neurologického deficitu, ktorý nastal po dobu najmenej 24 hod. IV. štádium - LIM - pretrvávajúci neurologicky deficit v priebehu 5 dní Tsivgoulis G. et al. Safety of early endarterectomy in patients with symptomatic carotid artery stenosis: an international multicenter study. Eur J Neurol. 2014, 21/10/:1251-7
5 KAROTICKÁ STENÓZA Za 20%-30% všetkých ischemických CMP zodpovedá extrakraniálna karotická stenóza Diagnostika /stupeň stenózy, charakter plátu/ - USG - CT-AG - MR-AG - DSA
6 Charakter ATS plátu KAROTICKÁ STENÓZA - výskyt mozgového infarktu z echoulcentných plátov 36%, z hyperechogénych plátov 6%
7 KAROTICKÁ ENDARTEREKTÓMIA /CEA/ Ošetrenie aterosklerotickej stenózy extrakraniálneho úseku karotickej tepny Najčastejšia tepenná operácia Chiari, Hunt - význam vyšetrenia krčných tepien pri pitve u pacientov s mozgovým infarktom Miller Fisher - oklúzia ACI príčinou mozgového infarktu 1951 Carrey, Molins, Murphy, 1954 Eastcott, Pickering, Robb - resekcia čiastočne strombotizovaného úseku ACI a rekonštrukcia priamou anastomózou DeBakey - CEA /1965/ Cooley, Al-Naaman,Carton - prvá publikácia Začiatok 80-tych rokov - Kasprzak, Raithel /Nemecko/, Kieny /Strasbourg/ - modifikácia DeBakey-ho techniky James, T. Robertson. A Saga of Clinical Science, Perosnalities and Evolving Technology. Stroke 1998, 29:
8 ESVS GUIDELINES INDIKÁCIE CEA CEA u symptomatických pacientov so stenózou viac ako 50%/70% pri komplikáciách <6%, do 2 týždňov od neurologickej symptomatológie [A] CEA u asymptomatických mužov <75rokov s 70-99% stenózou ACI pri komplikáciách <3%[A] Benefit CEA u asymptomatických žien je signifikatne menší ako u mužov[a] CAS u symptomatických pacientov vysoko rizikových pre CEA, vo veľkých centrách, s nízkym % komplikácií[a] Liapis, C.D. et al. ESVS Guidelines. Invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg 2009, 37, S1-S19
9 NYHA III a IV ESVS GUIDELINES INDIKÁCIE CAS Nestabilná angina pectoris št. III a IV V skorom období po IM So závažným respiračným ochorením Symptomatické restenózy po CEA Kontralaterálna porucha n. laryngeus reccurens, n.vagus, n. hypoglossus Hostile neck Vysoké vetvenie karotickej bifurkácie a pridružené intrakraniálne lézie alebo anomálie vo Willisovom okruhu Liapis, C.D. et al. ESVS Guidelines. Invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg 2009, 37, S1-S19
10 ESVS GUIDELINES UPDATE 2012 CEA je lepšia voľba ako CAS pri symptomatických pacientoch [A] BMT u asymptomatických vysoko rizikových pacientov [C] CEA u pacientov s vekom 80 rokov nezvyšuje riziko embolizácie, s akceptovateľným % neurologických a kardiálnych komplikácií [C] CAS je spojená s vysokým rizikom embolizácie u týchto pacientov [C] Kakisis, J.D. et al. The European Society fo Vascular Surgery Guidelines for Carotid Intervention:An updated independent assessment and literature review. Eur J Vasc Endovasc Surg 2012, 44,
11 AHA/ASA GUIDELINE GUIDELINES FOR THE PREVENTION OF STROKE IN PATIENTS WITH STROKE AND TIA 2014 CEA je doporučená u pacientov s TIA a CMP v priebehu posledných 6 mesiacov, so stenózou ACI 70-99%, pri <6% komplikáciách [Class I, Level of evidence A] BMT protidoštičková terapia, statíny, zníženie rizikových faktorov u pacientov s karotickou stenózou, TIA a CMP [Class I, Level of evidence A] CEA je doporučená u pacientov s 50-69% stenózou ACI po TIA/CMP s ohľadom na vek, pohlavie a komorbidity, pri <6% komplikáciách [Class I, Level of evidence B] Ak je revaskularizácia indikovaná u pacientov s TIA, minor stroke, CEA do 2 týždňov, ak nie sú kontraindikácie ku skorej revaskularizácií [Class IIa, Level of evidence B] CAS je indikovaná ako alternatíva CEA u symptomatických pacientov [Class IIa, Level of evidence B] U pacientov <70 rokov je CAS ekvivalentná ku CEA [Class IIa, Level of evidence B] CEA a CAS vykonávaná na pracoviskách s komplikáciami <6% [Class I, Level of evidence B] Walter, N.Kernan et al. Guidelines for the prevention of stroke in patients with stroke and transient oschemic attack,aha/asa guideline. Stroke 2014, 45,
12 RIZIKO CMP V HYPERAKÚTNOM OBDOBÍ PO TIA U PACIENTOV S 50-99% STENÓZOU ACI 48h 72h 7d 14d 5r ESCT+NASCET+VA (BMT) Fairhead et al. (2005) Purroy et al. (2007) 10% 20% Ois et al. (2009) 17% 22% 25% Bonifati et al. (2011) 8% Johansson et al. (2013) 5% 8% 11% Merwick et al. (2013) 8% Marname et al. (2014) 5% 9% 9% 16% 21% Naylor, A.R. Carotid endarterectomy is safer than stenting in hyperacute period after onset of symptoms. Eur J Vasc Endovasc Surg 2015, 49,
13 1991 ECST a NASCET CEA u pacientov s 50-99% stenózou ACI do 6 mesiacov od CMP znižuje 5-ročné riziko CMP v porovnaní s BMT Riziko CMP v skorom období po neurologickej symptomatológií je väčšie ako sa predpokladalo 8-17% v priebehu 72 hodín (zriedka alebo vôbec nezaradení v ECST/NASCET) NASCET, ECST, VA CEA do 14 dní s 10% procedurálnym rizikom zabráni v priebehu 5 rokov väčšiemu množstvu CMP ako pri čakaní 4 týždne s 0% rizikom Naylor, A.R. et al., Clinical and Imaging features associated with an increased risk of early and late stroke in patients with symptomatic carotid disease. Eur J Vasc Endovasc Surg 2015, 49,
14 30 DŇOVÉ RIZIKO CMP/SMRTI PO CEA V ZÁVISLOTI OD ČASU Stromberg et al. (2012) Sharpe et al. (2013) Rantner et al. (2015) 0-48h 3-7d 8-14d >14d 11,5% 3,6% 4,0% 5,4% 2,4% 1,8% 0,8% 0,7% 4,4% 1,8% 4,4% 2,5% Naylor, A.R. Carotid endarterectomy is safer than stenting in hyperacute period after onset of symptoms. Eur J Vasc Endovasc Surg 2015, 49,
15 CEA > CAS ICSS /International carotid stenting study/ - 8,7% procedurálne riziko do 14 dní US Cordis Carotid Stent Collaborative 8,8% procedurálne riziko do 14 dní EVA-3S 10,5% do 14 dní NASCET, ECST, VA 8-9% procedurálne riziko do 14 dní CEA je bezpečnejšia ako CAS v hyperakútnej fáze /do 48 hod./ po neurologickej symptomatológii Naylor, A.R. Carotid endarterectomy is safer than stenting in hyperacute period after onset of symptoms. Eur J Vasc Endovasc Surg 2015, 49,
16 KLINICKÝ MATERIÁL Január 2011 december CEA - 41 včasných CEA / do 16 dní/ Základná charakteristika súboru včasných CEA Priemerný vek,rok 74 Muži,% 53,7 Ženy,% 46,3 TIA,% 63,4 CMP,% 31,7 Amaurosis fugax,% 4,9 Stupeň stenózy 70-90%,% 39,0 Stupeň stenózy 90% a viac,% 61,0 Medián doby od posledných príznakov.dni 11
17 KLINICKÝ MATERIÁL CT mozgu Bez čerstvého ischemické ložiska mozgu 51,1% Čerstvé ischemické ložisko mozgu do 2,5cm 35,9% Staré ischemické zmeny 13,0% Typ komplikácií Počet (%) 30 dňová mortalita 0 FiP 2,4 CMP 4,8 Hematóm v rane 2,4
18 KLINICKÝ MATERIÁL V priebehu follow-up /1-24 mesiacov/ bola primárna aj sekundárna priechodnosť rekonštrukcií 100% Pri USG kontrolách bola preukázaná jedna restenóza Neboli zaznamenané recidívy CMP Infekčné komplikácie sa nevyskytli
19 ZÁVER Včasná CEA pre symptomatickú stenózu ACI predstavuje metódu s dobrými výsledkami a akceptovateľným rizikom komplikácií Sekundárna prevencia CMP / u 20-30% prítomná karotická stenóza/ Správny manažment /čím skôr, tým lepšie/ Spolupráca neurológ cievny chirurg Korelácia medzi nálezom hypodenzity na CT mozgu a CEA v závisloti na čase nie je jednoznačne potvrdená čím väčšie ischemické ložisko, tým väčšie pravdepodobnejšia hemoragická transformácia SPREAD-STACI trial randomizovaná - 2 skupiny do 48 hodín, 48 hodín 14 dní
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