無癥狀的頸動脈狹窄的介入治療應(yīng)該分情況對待英文

無癥狀的頸動脈狹窄的介入治療應(yīng)該分情況對待英文第1頁/共25頁2008Themechanismofstrokewith

carotidlesion

Emboli

Hypoperfusion

Clinicalsymptomscausedbyembolicdiseasein>80%ofpatients<20%byhemodynamicimpairment第2頁/共25頁2008PosteriorInferiorCerebellarArteryInternalCarotidArteryVertebralArteryAthroscleroticplaqueThrombusEmbolusOcclusivethrombusCerebralCirculationand

ThromboembolicLesionsWhyshouldtreatcarotidlesion？第3頁/共25頁2008CarotidArteryDiseasePatientsSymptomaticAsymptomatic25%75%CarotidStenosis第4頁/共25頁2008SymptomaticCarotidStenosisNaturalHistoryCarotidstenosis+TIARiskofstrokein1styr=12-13%

5thyr=30-37%

Sundtetal.,1987 Dennisetal.Stroke,1990第5頁/共25頁2008AsymptomaticCarotidStenosisNaturalHistoryStenoses>75% riskofstrokein1styr=2-5%

Roedereretal.Stroke,1984

Hennerecietal.Brain,1987第6頁/共25頁2008Majorstrokebystenosisseverity第7頁/共25頁2008Riskofstrokeinpatientswithasymptomaticcarotidstenosishasfallensignificantly.Abbottetal.,InternationalJournalofStroke,2007.第8頁/共25頁2008ATROCAP：

Atorvastatin20mgStabilizeplaque“Stabilizingplaqueisanimportantmechanismtoreducecardiovascularandcerebralevents.”MeanPercentchange

（%)-60-50-40-30-20-100UlcerationInflammationMacrophagePlacebo（n=30）Lipitor20mg（n=29）CortellaroMetal.ThrombHaemost.2002;88:41-47.第9頁/共25頁2008RiskStratificationofAsymptomaticCarotidStenosisEurJVascEndovascSurgxx,1e10(2008)第10頁/共25頁2008Plaquemorphology：“HighRisk”第11頁/共25頁2008“Vulnerable”plaqueincarotidspecimen第12頁/共25頁2008Lesionmorphologiesincarotidartery第13頁/共25頁2008PlaqueMorphologyandStrokeRiskUlceration=Iminentstroke riskofstroke= 7.5%

Autretetal.Lancet,1987Heterogeneousandulceratedlesions=Risk2-4x

Langsfeldetal.JVascSurg,1989

Sterpettietal.Stroke,1988

第14頁/共25頁2008WhatweknownowTheriskofstrokeisrelevanttoseverityofstenosisHistologicaldatafromthecoronaryandcarotidcirculationssuggestthatotherplaquefeaturesmaybemoreimportantinpredictingfuturethrombo-embolicevents.第15頁/共25頁2008RevascularizationforAsymptomaticCarotidStenosisStratificationStrategy第16頁/共25頁2008

頸動脈狹窄的治療方法

1．藥物治療（MedicalTherapy）2．頸動脈內(nèi)膜剝離術(shù)（CarotidEndarterectomy,CEA）3．經(jīng)皮頸動脈支架植入術(shù)（CarotidArteryStenting,CAS）

第17頁/共25頁2008TheCochraneCollaboration2006ASA2006第18頁/共25頁2008Step1：HighRiskofStrokeSevereCarotidStenosis（≥80%）+UnfavorablePlaqueFeatures

（ulcerationorheterogenecity

）第19頁/共25頁2008Step2：HighRiskforStentingHighriskPatients

>80yofage(asymptomatic)AccessproblemsBaselinelargeneurologicaldefectMarkedcerebralatrophy+microangiopathyDementia/AlzheimerHighriskAnatomyObviousfillingdefect/thrombusVesselocclusion“String”sign-asymptomaticSeveredistalloops/kinks/bendsHeavyconcentriccalcificationsTypeIIIaortaarch第20頁/共25頁2008Highriskforintervention第21頁/共25頁2008Any2ofthefollowing=HighRiskAGE≥80↓CerebralReserveExcessiveTortuosityHeavyconcentriccalcificationCriteriaofHighRiskCarotidStenting第22頁/共25頁2008ProposedNewParadigmCarotidRevascularizationIndicated?YesHighStentRis