颈动脉内膜剥脱术对预防中风所起的作用

CEA and Stroke Prevention in China Douglas J. Wirthlin, M.D. Division of Vascular Surgery Department of Cardiovascular Medicine Intermountain Health Care, Salt Lake City, Utah China population 1.27 billion US population 0.29 billion Stroke #1 cause of death 1.5 million new strokes/yr 1 million stroke deaths/yr Stroke #3 cause of death 0.5 million new strokes/yr 0.2 million stroke deaths/yr 1996-2000, 8258 strokes, 10 populations 75% CT scans Hemorrhagic 29.3% Ischemic 62.4% Embolic ? Intracranial ? Unknown ? Heart ? Carotid ? Stroke 2003;34:2091-6 Causes of Stroke in China 20 % Carotid Endarterectomy (CEA) in USA 200,000 cases/year CEA in China : 70% ) NEJM 325:445; 1991 NASCET (stenosis 70%) Medical Surgical Relative Risk Reduction 30 day stroke 3.3 % 5.8% Cumulative stroke 26% 9% 65% Fatal stroke 13.1% 2.5% 81% 2 yr stroke no 30 d stroke 12.2% 1.6% Asymptomatic Carotid Atherosclerosis Study (ACAS) NIH sponsered Asymptomatic patients (low surgical risk) w/ 60% stenosis Angiography not mandatory Angiographic related stroke 1.2 % * JAMA 273:1421, 1995 ACAS Surgery Medical 30 day stroke/mortality 2.3% 5 year ipsilateral stroke 5.1% 11% * JAMA 273:1421, 1995 History of CEA in USA CEA becomes the “gold standard” for treatment of extra-cranial carotid stenosis. Guidelines for CEA are established. Rate of CEA increases. (200,000 CEA/yr) Indications for CEA Asymptomatic 70 % stenosis 50 % stenosis w/ large ulcer TIA 70 % stenosis 50 % stenosis w/ large ulcer Previous Stroke Stable/Improving neurologic exam 70 % stenosis 50 % stenosis w/ large ulcer Evolving Stroke 70 % stenosis Global Symptoms 70 % stenosis and uncorrectable vertebrobasilar disease AHA Standards for CEA (1989) 30 day mortality 80 Cardiac CABG 50% FEV1 3.0 Anatomic Previous CEA Severe tandem lesion Cervical Radiation Contralateral carotid occlusion High cervical lesion C2 Lesion below clavicle Contralateral laryngeal palsy SAPPHIRE CEA CAS 30 day Stroke 3.3% 3.3% p0.99 MI 6.6% 4.4% p 60%) Stroke or death at 30 days and 6 months 30 day stroke/death CEA 3.9 %, CAS 9.6 % 2.5 relative risk increase for stroke/death CAS vs. CEA 6 month stroke/death CEA 6.1 %, CAS 11.2 % (p=0.02) Stopped after 527 patientd secondary to significant advantage of CEA NEJM 355:1660-1; 2006 Current Guidelines CEA or CAS? Good Surgical Risk Asymptomatic patients ? Symptomatic patients ? CREST trial High Surgical Risk Asymptomatic CAS vs. ? medical mgt. Symptomatic CAS ? History of Carotid Disease Treatment: USA and China First CEA 1954 Efficacy of CEA validated: ACAS, NASCET 1990s CAS developed 1990s CAS protection devices 2000 SAPHIRE 2004 CAS regulated by Government 2005 CAS outcomes inferior to CEA in Europe NEJM 2006 CEA Reports: 22 cases Shanghai 2002, 62 cases Hong Kong 2002 SinoAmerican Stroke Group 105 CEA, 2004 First CEA/CAS? 1990 - 2000 Resource Utilization & Cost Equipment Operating Room Surgical Instruments Personnel Trained Surgeon Anesthesiologist Cost Operative 13,389+4,937 RMB Total 24,151+2,557 RMB Equipment Angiography suite Wires, catheters, balloons, stents, protection device Personnel Trained Interventionalist Cost 70,000 RMB CEA CAS Cost of Treating Carotid Artery Disease Stroke CAS CEA Patient Education / Physician Education Risk Factor Modification Screening Programs Medicine CASCEA CVD Stroke Prevention Plan Patient Education / Physician Education Risk Factor Modification Screening Programs Medicine CASCEA CVD