无症状的颈动脉狭窄的介入治疗应该分情况对待英文课件

1、无症状的颈动脉狭窄的介入治疗应该分情况对待英文课件无症状的颈动脉狭窄的介入治疗应该分情况对待英文课件The mechanism of stroke with carotid lesion Emboli Hypoperfusion Clinical symptoms caused by embolic disease in 80% of patients 75%risk of stroke in 1st yr = 2-5% Roederer et al. Stroke, 1984 Hennereci et al. Brain, 19872008Asymptomatic Carotid Steno

2、sis Major stroke by stenosis severity2008Major stroke by stenosis severRisk of stroke in patients with asymptomatic carotid stenosis has fallen significantly.Abbott et al., International Journal of Stroke, 2007.2008Risk of stroke in patients witATROCAP： Atorvastatin 20mg Stabilize plaque“Stabilizing

3、 plaque is an important mechanism to reduce cardiovascular and cerebral events.”Mean Percent change （%)-60-50-40-30-20-100UlcerationInflammationMacrophagePlacebo（n=30）Lipitor20mg（n=29）Cortellaro M et al. Thromb Haemost. 2002;88:41-47.2008ATROCAP： Atorvastatin 20mg SRisk Stratification of Asymptomati

4、c Carotid StenosisEur J Vasc Endovasc Surg xx, 1e10 (2008)2008Risk Stratification of AsymptoPlaque morphology：“High Risk” 2008Plaque morphology：“High Risk” “Vulnerable” plaque in carotid specimen2008“Vulnerable” plaque in carotidLesion morphologies in carotid artery2008Lesion morphologies in carotid

5、Plaque Morphology and Stroke RiskUlceration = Iminent stroke risk of stroke = 7.5% Autret et al. Lancet, 1987Heterogeneous and ulcerated lesions = Risk 2-4 x Langsfeld et al. J Vasc Surg, 1989 Sterpetti et al. Stroke, 1988 2008Plaque Morphology and Stroke RWhat we know nowThe risk of stroke is relev

6、ant to severity of stenosisHistological data from the coronary and carotid circulations suggest that other plaque features may be more important in predicting future thrombo-embolic events. 2008What we know nowThe risk of stRevascularization for Asymptomatic Carotid StenosisStratification Strategy20

7、08Revascularization for Asymptom 颈动脉狭窄的治疗方法 1药物治疗 （Medical Therapy）2颈动脉内膜剥离术 （Carotid Endarterectomy, CEA）3经皮颈动脉支架植入术 （Carotid Artery Stenting, CAS） 2008 颈动脉狭窄The Cochrane Collaboration 2006 ASA 20062008The Cochrane Collaboration 200Step 1 ：High Risk of StrokeSevere Carotid Stenosis （80%） +Unfavorab

8、le Plaque Features （ulceration or heterogenecity ）2008Step 1 ：High Risk of StrokeSevStep 2 ：High Risk for StentingHigh risk Patients 80 y of age (asymptomatic)Access problemsBaseline large neurological defectMarked cerebral atrophy + microangiopathyDementia / Alzheimer High risk AnatomyObvious filli

9、ng defect / thrombusVessel occlusion“String” sign - asymptomatic Severe distal loops/kinks/bends Heavy concentric calcificationsType III aorta arch2008Step 2 ：High Risk for StentingHigh risk for intervention2008High risk for intervention2008Any 2 of the following = High RiskAGE 80Cerebral ReserveExcessive TortuosityHeavy concentric calcificationCriteria of High Risk Carotid Stenting2008Any 2 of the following = High Proposed New ParadigmCarotid Revascularization Indicated?YesNoHigh Stent RiskYesNoMedical ManagementSurveillanceC