颈动脉内膜剥脱术对预防中风所起的作用课件

1、CEA and Stroke Prevention in ChinaDouglas J. Wirthlin, M.D.Division of Vascular SurgeryDepartment of Cardiovascular MedicineIntermountain Health Care, Salt Lake City, UtahChina population 1.27 billionUS population 0.29 billionStroke #1 cause of death1.5 million new strokes/yr1 million stroke deaths/

2、yrStroke #3 cause of death0.5 million new strokes/yr0.2 million stroke deaths/yr 1996-2000, 8258 strokes, 10 populations 75% CT scans Hemorrhagic29.3%Ischemic62.4% Embolic?Intracranial?Unknown?Heart?Carotid?Stroke 2003;34:2091-6Causes of Stroke in China 20 %Carotid Endarterectomy (CEA) in USA 200,00

3、0 cases/yearCEA in China : 200 cases/yearWhy so few CEA in China? No formal training Poor outcomes (in the past) Patients present with advanced disease CEA developed concurrent with CAS Financial incentives for CAS over CEA Limited Referrals from medical doctors Patient fear of surgeryHistory of CEA

4、 in USAFirst CEA 19541960s 1980s improvement in surgical technique and understanding of cerebrovascular disease. History of CEA in USA1970s - 80s Efficacy of CEA questioned1990s Randomized trials establish CEA as the treatment of choice for high-grade carotid stenosis over “best medical therapy.” (N

5、ASCET & ACAS)North American Symptomatic Carotid Endarterectomy Trial (NASCET)50 centers US & Canada (qualified based on 70% )NEJM 325:445; 1991 NASCET (stenosis 70%)MedicalSurgicalRelative Risk Reduction30 day stroke3.3 %5.8%Cumulative stroke26%9% 65%Fatal stroke13.1%2.5% 81%2 yr stroke no 30 d stro

6、ke12.2%1.6%Asymptomatic Carotid Atherosclerosis Study (ACAS) NIH sponseredAsymptomatic patients (low surgical risk) w/ 60% stenosis Angiography not mandatoryAngiographic related stroke 1.2 %* JAMA 273:1421, 1995ACASSurgeryMedical30 day stroke/mortality2.3%5 year ipsilateral stroke5.1%11%* JAMA 273:1

7、421, 1995History of CEA in USACEA 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 CEAAsymptomatic 70 % stenosis 50 % stenosis w/ large ulcerTIA 70 % stenosis 50 % stenosis w/ large u

8、lcerPrevious StrokeStable/Improving neurologic exam 70 % stenosis 50 % stenosis w/ large ulcerEvolving Stroke 70 % stenosisGlobal Symptoms 70 % stenosis and uncorrectable vertebrobasilar diseaseAHA Standards for CEA (1989)30 day mortality 2 %Stroke RateAsymptomatic 3%TIA 5%Prior infarct 7%Recurrent

9、Stenosis 80CardiacCABG 6wksMI 4 wksAngina CCS class III/IVCHF III/IVEF 30%Abnl Stress testPulmonaryChronic Oxygen usePO2 50%FEV1 3.0AnatomicPrevious CEASevere tandem lesionCervical RadiationContralateral carotid occlusionHigh cervical lesion C2Lesion below clavicleContralateral laryngeal palsySAPPHI

10、RECEACAS30 dayStroke3.3%3.3%p0.99MI6.6%4.4%p 60%)Stroke or death at 30 days and 6 months30 day stroke/death CEA 3.9 %, CAS 9.6 %2.5 relative risk increase for stroke/death CAS vs. CEA6 month stroke/death CEA 6.1 %, CAS 11.2 % (p=0.02)Stopped after 527 patientd secondary to significant advantage of C

11、EANEJM 355:1660-1; 2006Current Guidelines CEA or CAS?Good Surgical RiskAsymptomatic patients ?Symptomatic patients ? CREST trialHigh Surgical Risk AsymptomaticCAS vs. ? medical mgt.Symptomatic CAS ?History of Carotid Disease Treatment: USA and ChinaFirst CEA1954Efficacy of CEA validated: ACAS, NASCE

12、T 1990sCAS developed 1990sCAS protection devices 2000SAPHIRE 2004CAS regulated by Government 2005CAS outcomes inferior to CEA in Europe NEJM 2006CEA Reports: 22 cases Shanghai 2002, 62 cases Hong Kong 2002SinoAmerican Stroke Group 105 CEA, 2004First CEA/CAS? 1990 - 2000Resource Utilization & CostEqu

13、ipmentOperating RoomSurgical InstrumentsPersonnelTrained SurgeonAnesthesiologistCostOperative 13,389+4,937 RMBTotal 24,151+2,557 RMBEquipmentAngiography suiteWires, catheters, balloons, stents, protection devicePersonnelTrained InterventionalistCost 70,000 RMBCEACASCost of Treating Carotid Artery DiseaseStroke CAS CEA Patient Education / Physician EducationRisk Factor ModificationScreening ProgramsMedicineCASCEACVD Stroke Prevention PlanPatient Education / Physician EducationRisk Factor Modific