颈动脉内膜剥脱术对预防中风所起的作用课件

CEAandStrokePreventioninChinaDouglasJ.Wirthlin,M.D.DivisionofVascularSurgeryDepartmentofCardiovascularMedicineIntermountainHealthCare,SaltLakeCity,Utah

CEAandStrokePreventionin颈动脉内膜剥脱术对预防中风所起的作用课件Chinapopulation~1.27billionUSpopulation~0.29billionStroke–#1causeofdeath1.5millionnewstrokes/yr1millionstrokedeaths/yrStroke–#3causeofdeath0.5millionnewstrokes/yr0.2millionstrokedeaths/yrChinapopulation~1.27billio3

1996-2000,8258strokes,10populations>75%CTscans

Hemorrhagic29.3%Ischemic62.4%

Embolic?Intracranial?Unknown?Heart?Carotid?Stroke2003;34:2091-6CausesofStrokeinChina~20%1996-2000,8258strokes,Hem颈动脉内膜剥脱术对预防中风所起的作用课件颈动脉内膜剥脱术对预防中风所起的作用课件颈动脉内膜剥脱术对预防中风所起的作用课件颈动脉内膜剥脱术对预防中风所起的作用课件颈动脉内膜剥脱术对预防中风所起的作用课件CarotidEndarterectomy(CEA)inUSA<2%mortality0-5%strokerate1-2dayLOS~10xreductioninstrokeriskCarotidEndarterectomy(CEA)iNorthAmericanSymptomaticCarotidEndarterectomyTrial(NASCET)NEJM325:445;1991AsymptomaticCarotidAtherosclerosisStudy(ACAS)*JAMA273:1421,1995CEAonlyeffectiveif:1.outcomesaregood2.expectedpatientsurvival2-5yearsNorthAmericanSymptomaticCarCarotidEndarterectomyinMainlandChinaDouglasJWirthlinMD,QinYiZhangMD,GenXueQuMD,JianLinLiuMD,XengMengMD,RaphaelCSunBS,NaiDongWangMD,DonaldBDotyMD.XianJianTongUniversityNo.1Xian,People’sRepublicofChinaIntermountainHealthCare,LDSHospital,SaltLakeCity,UtahCarotidEndarterectomyinMainFebruary2002–presentFebruary2002–July20042exchangesinUSA2exchangesinChinaFebruary2002–presentResults(4/02-7/04)104CEAperformedin4hospitalsUSsurgeon(3cases)Results(4/02-7/04)104CEAperDemographics65CEAin60patients48male,12femaleHypertension 47(78%)Hypercholesterolemia 57(95%)Smoking 31(52%)Diabetes 14(23%)Demographics65CEAin60patieNeurologicPresentationAsymptomatic 0(0%)TIA 4(7%)Stroke 61(93%)Minor 36(67%)Major 22(33%)NeurologicPresentation62y/omanSmoking,HTNRMOBLSidedweaknessBilateralICAocclusions62y/oman颈动脉内膜剥脱术对预防中风所起的作用课件OperativeTechniqueGeneralAnesthesia 64(98%)Shunt 64(98%)LongitudinalEndart. 65(100%)Primaryclosure 59(91%)Prostheticpatch 6(9%)OperativeTechniqueGeneralAne30dayOutcomesMortality 0(0%)MI 0(0%)Neurologicevents 4(6%)Major 3(5%)Minor(TIA) 1(2%)CNinjury 6(10%)Bleeding 1(2%)30dayOutcomesMortality 0(LOS/HospitalChargesMeanLOS 26+20days(10-127d)MeanOperativeCharges 13,389+4937RMB~(1,613+595US$)MeanTotalCharges24,151+2557RMB~(2,909+308US$)LOS/HospitalChargesMeanLOS Withadequatetraining,CarotidEndarterectomy(CEA)inChinaisverysafeandeffectiveWithadequatetraining,CarotiCEAinUSA:>200,000cases/yearCEAinChina:<200cases/yearCEAinUSA:>200,000cases/WhysofewCEAinChina?NoformaltrainingPooroutcomes(inthepast)PatientspresentwithadvanceddiseaseCEAdevelopedconcurrentwithCASFinancialincentivesforCASoverCEALimitedReferralsfrommedicaldoctorsPatientfearofsurgeryWhysofewCEAinChina?HistoryofCEAinUSAFirstCEA19541960’s–1980’simprovementinsurgicaltechniqueandunderstandingofcerebrovasculardisease.

HistoryofCEAinUSAFirstCEAHistoryofCEAinUSA1970’s-80’sEfficacyofCEAquestioned1990’sRandomizedtrialsestablishCEAasthetreatmentofchoiceforhigh-gradecarotidstenosisover“bestmedicaltherapy.”(NASCET&ACAS)HistoryofCEAinUSA1970’s-NorthAmericanSymptomaticCarotidEndarterectomyTrial(NASCET)50centersUS&Canada(qualifiedbasedon<5%morbidity&mortalityfollowingCEA)Patientsymptoms(Lowsurgicalrisk):TIAorminorstrokew/in3monthsLesionclassified:30-69%or70-99%659pts331ECASA328CEA+ECASAStoppedafter18mo.Meanf/usecondarytosignificantadvantageofCEA(stenosis>70%)NEJM325:445;1991NorthAmericanSymptomaticCarNASCET(stenosis>70%)MedicalSurgicalRelativeRiskReduction30daystroke3.3%5.8%Cumulativestroke26%9%65%Fatalstroke13.1%2.5%81%2yrstrokeno30dstroke12.2%1.6%NASCET(stenosis>70%)MedicAsymptomaticCarotidAtherosclerosisStudy(ACAS)

NIHsponseredAsymptomaticpatients(lowsurgicalrisk)w/>60%stenosis

AngiographynotmandatoryAngiographicrelatedstroke1.2%*JAMA273:1421,1995AsymptomaticCarotidAtherosclACASSurgeryMedical30daystroke/mortality2.3%5yearipsilateralstroke5.1%11%*JAMA273:1421,1995ACASSurgeryMedical30daystrokHistoryofCEAinUSACEAbecomesthe“goldstandard”fortreatmentofextra-cranialcarotidstenosis.GuidelinesforCEAareestablished.RateofCEAincreases.(200,000CEA/yr)HistoryofCEAinUSACEAbecomIndicationsforCEAAsymptomatic>70%stenosis>50%stenosisw/largeulcerTIA>70%stenosis>50%stenosisw/largeulcerPreviousStrokeStable/Improvingneurologicexam>70%stenosis>50%stenosisw/largeulcerEvolvingStroke>70%stenosisGlobalSymptoms>70%stenosisanduncorrectablevertebrobasilardiseaseIndicationsforCEAAsymptomatiAHAStandardsforCEA(1989)30daymortality<2%StrokeRateAsymptomatic<3%TIA<5%Priorinfarct<7%RecurrentStenosis<10%CEAonlyeffectiveif:1.outcomesaregood2.expectedpatientsurvival2-5yearsAHAStandardsforCEA(1989)30HistoryofCEAinUSA1990’sCarotidAngioplastyandStent(CAS)introduced.2000CerebralprotectiondevicesintroducedandoutcomesofCASappearcomparabletoCEA.RandomizedprospectivetrialestablishesCASequivalenttoCEAinhigh-risksymptomaticpatients(SAPPHIRE).CurrentlytheroleofCEAisbeingredefined.HistoryofCEAinUSA1990’sCaHistoryofCEAinChinaStrokeawareness,prevention,andtreatmentrecentlybecameapriorityforChinaNoformaltrainingforCEA.FewreportsofCEAinChina22CEA,ZhongshanHospital,FudanUniversity,Shanghai(ChinMedJ2002;115(3):405-862CEA,QueenMaryHospital,UniversityofHongKongMedicalCenter,HongKong(ChinMedJ2002;115(4):536-9105CEA,Sino-AmericanStrokeGroupCASisrapidlybecominganacceptedtreatmentoptionforcarotidstenosis.HistoryofCEAinChinaStrokeCarotidRevascularization:whichisbetter?10-15%CEAnotpossible10-15%CASnotpossible70-80%couldhaveeitherPatientsneedingcarotidrevascularizationCarotidRevascularization:whClinicalEffectivenessCaseSeries(w/cerebralprotection)AllpatientsPerioperativeoutcomesofCEAandCAScomparable~0-5%strokeanddeathrateCranialNerveDeficitCEA0–10%CAS0%RestenosisCEA0–20%,~4%clinicallysignificantCAS5–10%@12-24months,mostretreatedwithPTA/stentClinicalEffectivenessCaseSerProtectedCarotid-ArteryStentingversusEndarterectomyinHigh-RiskPatients(SAPPHIRE)Randomized,prospectivetrialinhighlyqualifiedcentersforbothCEAandCAS334High-riskpatients(asymptomaticandsymptomatic)randomized.DesignedtodetermineifCASisinferiortoCEAEndpoints:stroke,MI,death,andcranialnerveinjury(30dayand12month)NEJM2004351(15):1493-1501ProtectedCarotid-ArteryStentSAPPHIREHigh-riskCriteriaAge >80Cardiac CABG<6wks MI<4wks AnginaCCSclassIII/IV CHFIII/IV EF<30% AbnlStresstestPulmonary ChronicOxygenuse PO2<60mmHg Hct>50% FEV1<50%predictedRenal Creatinine>3.0Anatomic PreviousCEA Severetandemlesion CervicalRadiation Contralateralcarotidocclusion HighcervicallesionC2 Lesionbelowclavicle Contralaterallaryngealpalsy

SAPPHIREHigh-riskCriteriaAgeSAPPHIRECEACAS30dayStroke3.3%3.3%p>0.99MI6.6%4.4%p<0.05Death2.0%0.6%p=0.36All9.9%4.4%p=0.081yearStroke3.5%0%p=0.02MI8.1%2.5%p=0.03DeathAll20.1%12%p=0.05SAPPHIRECEACAS30dayStroke3.3%EndarterectomyversusStentinginPatientswithSevereCarotidStenosisMulticenter,randomizedeuropeantrial,symptomaticpatients(stenosis>60%)Strokeordeathat30daysand6months30daystroke/deathCEA3.9%,CAS9.6%2.5relativeriskincreaseforstroke/deathCASvs.CEA6monthstroke/deathCEA6.1%,CAS11.2%(p=0.02)Stoppedafter527patientdsecondarytosignificantadvantageofCEANEJM355:1660-1;2006EndarterectomyversusStentingCurrentGuidelines–CEAorCAS?GoodSurgicalRiskAsymptomaticpatients?Symptomaticpatients?CRESTtrialHighSurgicalRiskAsymptomatic CASvs.?medicalmgt.Symptomatic CAS?CurrentGuidelines–CEAorCAHistoryofCarotidDiseaseTreatment:USAandChinaFirstCEA1954EfficacyofCEAvalidated:ACAS,NASCET1990’sCASdeveloped1990’sCASprotectiondevices2000SAPHIRE2004CASregulatedbyGovernment2005CASoutcomesinferiortoCEAinEuropeNEJM2006CEAReports:22casesShanghai2002,62casesHongKong2002SinoAmericanStrokeGroup