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XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio 2005 - Montecatini Terme 1 Edoardo Croce.

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Presentazione sul tema: "XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio 2005 - Montecatini Terme 1 Edoardo Croce."— Transcript della presentazione:

1 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme 1 Edoardo Croce

2 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme2 1980: I procedura endovascolare Kerber CW, Cromwell LD, Loehden OL. Catheter dilatation of proximal carotid stenosis during distal bifurcation endarterectomy. AJNR Am J Neuroradiol. 1980; 1: 348– : I endarterectomia carotidea per TIA Eastcott HH, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet. 1954; 267: 994–996.

3 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme3 Migliaia di lavori in letteratura ma pochissimi trials multicentrici,randomizzati, prospettici, controllati

4 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme4 Randomized Trials of Symptomatic Patients European Carotid Surgery Trial North American Symptomatic Carotid Endarterectomy Trial Veterans Affairs Cooperative Carotid Trial Randomized Trials of Asymptomatic Patients Asymptomatic Carotid Atherosclerosis Study Veterans Affairs Cooperative Study European Carotid Surgery Trial Mayo Asymptomatic Carotid Endarterectomy Study Carotid Endarterectomy

5 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme5 Carotid Endarterectomy These trials have demonstrated that surgical carotid endarterectomy confers a significant benefit over best current medical management in patients with symptomatic carotid stenosis > 70% with lesser degrees of benefit in symptomatic lesions of 50% to 69% and asymptomatic lesions of >60%.

6 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme6 The Lancet 2003; 361: Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis PM Rothwell, M Eliasziw, SA Gutnikov, AJ Fox, DW Taylor, MR Mayberg, CP Warlow and HJM Barnett Surgery increased the 5-year risk of ipsilateral ischaemic stroke in patients with less than 30% stenosis (n=1746, absolute risk reduction 2·2%, p=0·05), had no effect in patients with 30–49% stenosis (1429, 3·2%, p=0·6), was of marginal benefit in those with 50–69% stenosis (1549, 4·6%, p=0·04), and was highly beneficial in those with 70% stenosis or greater without near-occlusion (1095, 16·0%, p<0·001). There was a trend towards benefit from surgery in patients with near-occlusion at 2 years' follow-up (262, 5·6%, p=0·19), but no benefit at 5 years (1·7%, p=0·9). Stenosi sintomatica

7 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme7

8 8 CMAJ August 31, 2004; 171 The inappropriate use of carotid endarterectomy Henry J.M. Barnett

9 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme9 Authors' conclusions: There is some evidence favouring CEA for asymptomatic carotid stenosis, but the effect is at best barely significant, and extremely small in terms of absolute risk reduction. From The Cochrane Library, Issue 2, Chichester, UK: John Wiley & Sons, Ltd. Carotid endarterectomy for asymptomatic carotid stenosis (Cochrane Review) Chambers BR, You RX, Donnan GA Carotid endarterectomy for symptomatic carotid stenosis (Cochrane Review) Cina CS, Clase CM, Haynes RB. Authors' conclusions: Carotid endarterectomy reduced the risk of disabling stroke or death for patients with stenosis exceeding ECST-measured 70% or NASCET-measured 50%. This result is generalizable only to surgically-fit patients operated on by surgeons with low complication rates (less than 6%).

10 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme10 Systematic Review of the Risks of Carotid Endarterectomy in Relation to the Clinical Indication for and Timing of Surgery R. Bond, MBBS, FRCS; K. Rerkasem, MD, FRCS; P.M. Rothwell, MD, PhD, FRCP Risk in patients with ocular events only tended to be lower than for asymptomatic stenosis Operative risk was the same for stroke and cerebral transient ischemic attack but higher for cerebral transient ischemic attack than for ocular events only Risk in CEA for restenosis is much higher than in primary surgery Urgent CEA for evolving symptoms had a much higher risk than CEA for stable symptoms There is no difference between early ( 3 to 6 weeks) CEA for stroke in stable patients (Stroke. 2003;34:2290.)

11 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme11 The Lancet 2004; 363: Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery PM Rothwell, M Eliasziw, SA Gutnikov, CP Warlow and HJM Barnett 5893 patients with patient-years of follow-up were analysed. Sex (p=0·003), age (p=0·03), and time from the last symptomatic event to randomisation (p=0·009) modified the effectiveness of surgery. Benefit from surgery was greatest in men, patients aged 75 years or older, and those randomised within 2 weeks after their last ischaemic event, and fell rapidly with increasing delay. For patients with 50% or higher stenosis, the number of patients needed to undergo surgery (ie, number needed to treat) to prevent one ipsilateral stroke in 5 years was nine for men versus 36 for women, five for age 75 years or older versus 18 for younger than 65 years, and five for those randomised within 2 weeks after their last ischaemic event, versus 125 for patients randomised after more than 12 weeks. Stenosi sintomatica

12 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme12 Two large trials involving asymptomatic patients have presented evidence that there is modest benefit favouring CE in subjects with stenosis but no symptoms, provided that highly skilled surgeons are involved and that complication rates are below 3%. Even with this low operative complication rate, the number needed to treat to prevent 1 stroke in 2 years is 83. In the 2 large trials involving a total of nearly 4500 patients, the annual stroke and death rate after CE was 1%, versus 2% among those without CE. Barnett, H. J.M. CMAJ 2004;171: Stenosi asintomatica

13 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme13 Variations in rates of appropriate and inappropriate carotid endarterectomy for stroke prevention in 4 Canadian provinces James Kennedy, Hude Quan, William A. Ghali and Thomas E. Feasby Appropriate procedures 78.2% (176/225) in Saskatchewan 58.7% (481/819) in Alberta 49.1% (350/713) in Manitoba 46.0% (649/1410) in British Columbia CMAJ August 31, 2004; 171 (5). doi: /cmaj

14 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme14 SINTOMATICITÀ FrequenzaPercentuale Percentuale cumulata ASINTOMATICO222553,5 SINTOMATICO171841,394,9 NON CLASSIFICATO2125,1100,0 Totale ,0

15 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme15 Evoluzione dellateroma carotideo

16 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme16

17 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme17 Circolo di Willis

18 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme18 SHUNT FrequenzaPercentuale Percentuale cumulata NO338281,4 SI77318,6100,0 Totale ,0

19 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme19 Paziente asintomatico TAC negativa no shunt Placca stabile – Buon circolo di Willis Intervento inutile

20 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme20 Paziente asintomatico TAC negativa shunt Placca stabile – Scarso circolo di Willis Intervento utile se stenosi emodinamica

21 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme21 Paziente asintomatico lesioni TAC no shunt Placca instabile – Buon circolo di Willis Intervento utile

22 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme22 Paziente asintomatico lesioni TAC shunt Placca instabile – scarso circolo di Willis Intervento utile

23 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme23 Paziente sintomatico (?) tac negativa no shunt Placca stabile – Buon circolo di Willis Intervento inutile

24 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme24 Paziente sintomatico tac negativa shunt Placca stabile – Scarso circolo di Willis Intervento utile

25 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme25 Paziente sintomatico lesioni TAC no shunt Placca instabile – Buon circolo di Willis Intervento utile

26 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme26 Paziente sintomatico lesioni TAC shunt Placca instabile – Scarso circolo di Willis Intervento utile

27 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme27 The Carotid and Vertebral Transluminal Angioplasty Study (CAVATAS) No significant difference in the risk of stroke or death related to the procedure between carotid endarterectomy and angioplasty The Wallstent Trial This trial was stopped early because of poor results from stenting. The Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) Perioperative stroke and death rates: 7.3% for surgery versus 4.4% for stenting. Rates of myocardial infarction were 7.3% for surgery versus 2.6% for stenting. Carotid Revascularization Endarterectomy versus Stent Trial (CREST) currently in progress Carotid Stenting

28 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme28 The Centers for Medicare & Medicaid Services (CMS) proposes the following regarding Carotid Stenting: The evidence is adequate to conclude that carotid artery stenting (CAS) with embolic protection is reasonable and necessary for patients who are at high risk for carotid endarterectomy (CEA) and who also have symptomatic carotid artery stenosis > 70%. Coverage is limited to these procedures using FDA approved carotid artery stenting systems and embolic protection devices. Patients at high risk for CEA are defined as having significant comorbidities and/or anatomic risk factors (i.e., recurrent stenosis and/or previous radical neck dissection), and would be poor candidates for CEA in the opinion of a surgeon.

29 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme29 What is High Risk? Serious Co-Morbid Medical Condition Congestive heart failure (class III/IV0 and /or known severe left ventricular dysfunction LVEF <30% Open Heart Surgery needed within six weeks Recent MI (>24 hrs. and <4 weeks) Unstable angina (CCS class III/IV) Severe pulmonary disease Anatomic Challenges Contralateral carotid occlusion Contralateral laryngeal nerve palsy Radiation therapy to neck Previous CEA with recurrent stenosis High cervical ICA lesions or CCA lesions below the clavicle Severe tandem lesions Age >80 years

30 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme30 What is High Risk Hostile Neck J Vasc Surg 2004; 40:254-61

31 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme31 The degree of carotid artery stenosis should be measured by duplex Doppler ultrasound or carotid artery angiography and recorded in the patient medical records. If the stenosis is measured by ultrasound prior to the procedure, then the degree of stenosis must be confirmed by angiography at the start of the procedure. If the stenosis is determined to be less than 70% by angiography, then CAS should not proceed. CMS Guidelines for Carotid Stenting

32 XXIV CONGRESSO NAZIONALE ACOI 25/28 Maggio Montecatini Terme32 27th Charing Cross International Symposium 27th Charing Cross International Symposium There is no satisfactory high level evidence that carotid stenting is effective Aprile 2005


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