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S.C. Angiologia Medica - Messina. Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke statistics--2008 update: a report from the American Heart.

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Presentazione sul tema: "S.C. Angiologia Medica - Messina. Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke statistics--2008 update: a report from the American Heart."— Transcript della presentazione:

1 S.C. Angiologia Medica - Messina

2 Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke statistics update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008;117:e S.C. Angiologia Medica - Messina

3 European Journal of Neurology 2006, 13: 581–598

4 S.C. Angiologia Medica - Messina T. Willis (1621–1675) J. Wepfer (1620–1695) M. E. DeBakey ( )

5 20 to 30% of strokes are caused by atherosclerotic carotid artery disease 1 Carotid artery disease increases the risk for stroke: By plaque or clot breaking off from the carotid arteries and blocking a smaller artery in the brain By narrowing of the carotid arteries due to plaque build-up By a blood clot becoming wedged in a carotid artery narrowed by plaque Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for Asymptomatic Carotid Artery Stenosis. JAMA 1995;273:1421 S.C. Angiologia Medica - Messina

6 Stroke. 2010;41:

7 Inzitari, D. et al. N Engl J Med 2000;342: S.C. Angiologia Medica - Messina

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10 Come definirla ? a rischio (embolico o emodinamico) instabile in progressione vulnerabile

11 Placca che determina una stenosi > 70 % (anche se di ecostruttura omogenea) Placca che determina una stenosi > 50%, disomogenea o con superficie microulcerata. Placca macro-ulcerata Placca emorragica De Fabritiis, Scondotto et al, 1988 S.C. Angiologia Medica - Messina

12 Superficie fortemente irregolare Capuccio fibroso sottile Presenza di core anecogeno ampio La percentuale di stenosi non è più rilevante J.Willet Cerebrovasc Dis. 10 suppl. 5, 2000 S.C. Angiologia Medica - Messina

13 Stroke. 2006;37:

14 S.C. Angiologia Medica - Messina

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17 Flogosi (la placca recentemente sintomatica presenta i nfiltrazioni di macrofagi e linfociti T) Neovascolarizzazione (contiene microvasi immaturi) Fattori plasmatici dellangiogenesi e della flogosi nei pazienti sintomatici Infezione (cellule correlate alla presenza di sostanze batteriche o virali) Connessione fra infezione e placca sintomatica S.C. Angiologia Medica - Messina

18 Susceptibility of a plaque to rupture thus causing a clinical cardiovascular event. % stenosi > 70% pressione parietale/shear stress basso e incostante infiammazione/neovascolarizzazione cappuccio fibroso sottile fissurazione cappuccio fibroso denudazione endoteliale ampia presenza di lipidi S.C. Angiologia Medica - Messina

19 Radiology :

20 SYMPTOMATIC PATIENTS p <.001 p =.045 S.C. Angiologia Medica - Messina

21 ns p <0.01 p <0.001 CEA vs MEDICAL Asymptomatic Stenosis S.C. Angiologia Medica - Messina

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24 Relationship Between Severity of Stenosis and Stroke Rate Stenosis NASCET (2 year)ECST (3 years)ACAS (3 years) 60%-69% 42813%13711%1316% 70%-79% 4321%1709%945% 80%-89% 3327%15921%NS 90%-99% 2435%6032%NS 80%-99% 5731%21924%883% Stroke. 2000;31:

25 S.C. Angiologia Medica - Messina Estimates of NNT with CEA to prevent 1 stroke in 2 years by age and degree of stenosis Patient groupNNT Symptomatic 70% stenosis age < 75 yr 6 70% stenosis age 75 yr 3 50%-69% stenosis 15 < 50% No benefit Asymptomatic > 60% stenosis 83 CMAJ AUG. 31, 2004; 171 (5)

26 S.C. Angiologia Medica - Messina

27 Stroke. 2010;41:e11-e17.

28 I pazienti con una stenosi carotidea in progressione sono ad alto rischio per eventi maggiori alle coronarie ed alla circolazione periferica e cerebrale (MACE : IMA, Stroke, Amputazione, Morte) Linfiammazione al centro della disfunsione endoteliale e della crescita della placca Ripetuti controlli ECD dovrebbero essere eseguiti nei pazienti con placche e stenosi moderate alla ricerca di una malattia progressiva S.C. Angiologia Medica - Messina

29 Number of Events in Patients With and Without CAS (during follow up) Asynt CAS (n 221) No Asyntom (n 2463) Non vascular death8%3% Vascular death15%5% MI13%6% Ischemic Stroke3%2% All first vascular events20%9% CEA6%0% Endovascular interventation2% Stroke. 2007;38:

30 S.C. Angiologia Medica - Messina From: Screening for Carotid Artery Stenosis: U.S.Preventive Services Task Force Recommendation Statement

31 S.C. Angiologia Medica - Messina Comment: The perceived effectiveness and cost-effectiveness of carotid duplex ultrasound surveillance programs should be questioned. The study raises a significant question: Do carotid duplex surveillance programs primarily benefit physicians, vascular laboratories, or patients? The fact that 40% of the patients had only two duplex ultrasound scans performed during the surveillance period is a serious study limitation. Follow-up was, however, comparable to other studies in the literature and therefore the results likely can be generally applied to other practices. The personal and economic impact of stroke is huge, but this report still calls into serious question the use of limited health care resources to fund carotid duplex surveillance programs. Conclusion: Carotid duplex ultrasound surveillance programs are costly and inefficient.

32 S.C. Angiologia Medica - Messina Despite these advances in understanding the pathophysiology of atherosclerotic plaque, the utility of morphological, pathological, and biochemical features in predicting the occurrence of TIA, stroke, or other symptomatic manifestations of ECVD has not been established clearly by prospective studies.

33 S.C. Angiologia Medica - Messina

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36 Conceptually, the presence of a vulnerable plaque is, by definition, a probabilistic entity. It does not denote the occurrence of an event at present but rather a higher risk for such occurrence in the future relative to a non vulnerable or less vulnerable plaque. As such, before it is widely adopted by clinicians, plaque vulnerability (if validated) should be able to provide incremental predictive value on top of currently available methods of risk stratification, which may be less expensive and less invasive than the methods proposed to detect vulnerable plaques.

37 S.C. Angiologia Medica - Messina Moreover, the complex implications of such a probabilistic diagnosis are exemplified in the observation that not all plaques that rupture (the basis for the classic definition of the term) actually result in a clinical cardiovascular event. Some plaques would rupture and then become quiescent and heal without causing a myocardial infarction or stroke (so called silent plaque rupture). Conversely, not all acute cardiovascular events are the result of plaque rupture because non ruptured plaques have been implicated as culprit lesions nearly one third of the time in autopsy series.


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