頸動(dòng)脈內(nèi)膜剝脫術(shù)對(duì)預(yù)防中風(fēng)所起的作用課件

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

CEAandStrokePreventionin頸動(dòng)脈內(nèi)膜剝脫術(shù)對(duì)預(yù)防中風(fēng)所起的作用課件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頸動(dòng)脈內(nèi)膜剝脫術(shù)對(duì)預(yù)防中風(fēng)所起的作用課件頸動(dòng)脈內(nèi)膜剝脫術(shù)對(duì)預(yù)防中風(fēng)所起的作用課件頸動(dòng)脈內(nèi)膜剝脫術(shù)對(duì)預(yù)防中風(fēng)所起的作用課件頸動(dòng)脈內(nèi)膜剝脫術(shù)對(duì)預(yù)防中風(fēng)所起的作用課件頸動(dòng)脈內(nèi)膜剝脫術(shù)對(duì)預(yù)防中風(fēng)所起的作用課件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頸動(dòng)脈內(nèi)膜剝脫術(shù)對(duì)預(yù)防中風(fēng)所起的作用課件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