無癥狀的頸動脈狹窄的介入治療應(yīng)該分情況對待英文

1、GDPPH, JF Luo2008The mechanism of stroke with carotid lesion Emboli HypoperfusionClinical symptoms caused by embolic disease in 80% of patientsn 75%risk of stroke in 1st yr = 2-5% Roederer et al. Stroke, 1984 Hennereci et al. Brain, 1987GDPPH, JF Luo2008Major stroke by stenosis severityGDPPH, JF Luo

2、2008Risk of stroke in patients with asymptomatic carotid stenosis has fallen significantly.Abbott et al., International Journal of Stroke, 2007.GDPPH, JF Luo2008ATROCAP： Atorvastatin 20mg Stabilize plaque“Stabilizing plaque is an important mechanism to reduce cardiovascular and cerebral events.”Mean

3、 Percent change （%)-60-50-40-30-20-100UlcerationInflammationMacrophagePlacebo（n=30）Lipitor20mg（n=29）Cortellaro M et al. Thromb Haemost. 2002;88:41-47.GDPPH, JF Luo2008Risk Stratification of Asymptomatic Carotid StenosisEur J Vasc Endovasc Surg xx, 1e10 (2008)GDPPH, JF Luo2008Plaque morphology：“High

4、Risk” GDPPH, JF Luo2008“Vulnerable” plaque in carotid specimenGDPPH, JF Luo2008Lesion morphologies in carotid arteryGDPPH, JF Luo2008Plaque Morphology and Stroke Risk Ulceration = Iminent stroke risk of stroke = 7.5% Autret et al. Lancet, 1987 Heterogeneous and ulcerated lesions = Risk 2-4 x Langsfe

5、ld et al. J Vasc Surg, 1989 Sterpetti et al. Stroke, 1988 GDPPH, JF Luo2008What we know now The risk of stroke is relevant to severity of stenosis Histological data from the coronary and carotid circulations suggest that other plaque features may be more important in predicting future thrombo-emboli

6、c events. GDPPH, JF Luo2008Revascularization for Asymptomatic Carotid StenosisStratification StrategyGDPPH, JF Luo2008 1藥物治療藥物治療 （Medical Therapy）2頸動脈內(nèi)膜剝離術(shù)頸動脈內(nèi)膜剝離術(shù) （Carotid Endarterectomy, CEA）3經(jīng)皮頸動脈支架植入術(shù)經(jīng)皮頸動脈支架植入術(shù) （Carotid Artery Stenting, CAS） GDPPH, JF Luo2008The Cochrane Collaboration 2006 ASA 2

7、006GDPPH, JF Luo2008Step 1 ：High Risk of Stroke Severe Carotid Stenosis （80%） + Unfavorable Plaque Features （ulceration or heterogenecity ）GDPPH, JF Luo2008Step 2 ：High Risk for StentingHigh risk Patients 80 y of age (asymptomatic)Access problemsBaseline large neurological defectMarked cerebral atro

8、phy + microangiopathyDementia / Alzheimer High risk AnatomyObvious filling defect / thrombusVessel occlusion“String” sign - asymptomatic Severe distal loops/kinks/bends Heavy concentric calcificationsType III aorta archGDPPH, JF Luo2008High risk for interventionGDPPH, JF Luo2008Any 2 of the followin

9、g = High RiskAGE 80Cerebral ReserveExcessive TortuosityHeavy concentric calcificationCriteria of High Risk Carotid StentingGDPPH, JF Luo2008Proposed New ParadigmCarotid Revascularization Indicated?YesHigh Stent RiskYesCEA if low riskNoCarotid StentNoMedical ManagementSurveillanceNeed good trainingDo

10、nt forget optimal medical therapy !GDPPH, JF Luo2008Thank you !GDPPH, JF Luo2008The mechanism of stroke with carotid lesion Emboli HypoperfusionClinical symptoms caused by embolic disease in 80% of patientsn 20% by hemodynamic impairmentGDPPH, JF Luo2008PosteriorInferiorCerebellarArteryInternalCarot

11、idArteryVertebralArteryAthroscleroticplaqueThrombusEmbolusOcclusivethrombusCerebral Circulation andThromboembolic LesionsWhy should treat carotid lesion？GDPPH, JF Luo2008Symptomatic Carotid Stenosis Natural History Carotid stenosis + TIA Risk of stroke in 1st yr = 12-13% 5th yr = 30-37% Sundt et al.

12、, 1987 Dennis et al. Stroke, 1990GDPPH, JF Luo2008Risk Stratification of Asymptomatic Carotid StenosisEur J Vasc Endovasc Surg xx, 1e10 (2008)GDPPH, JF Luo2008Plaque Morphology and Stroke Risk Ulceration = Iminent stroke risk of stroke = 7.5% Autret et al. Lancet, 1987 Heterogeneous and ulcerated lesions = Risk 2-4 x Langsfeld et al. J Vasc Surg, 1989