無癥狀的頸動脈狹窄的介入治療應該分情況對待-英文課件

InterventionforAsymptomaticCarotidStenosisshouldbeStratified

羅建方廣東省人民醫(yī)院JianfangLuo,M.D.GuangdongCardiovascularInstituteGuangdongProvincialPeople’sHospital20088Themechanismofstrokewith

carotidlesion

Emboli

Hypoperfusion

Clinicalsymptomscausedbyembolicdiseasein>80%ofpatients<20%byhemodynamicimpairment20088PosteriorInferiorCerebellarArteryInternalCarotidArteryVertebralArteryAthroscleroticplaqueThrombusEmbolusOcclusivethrombusCerebralCirculationand

ThromboembolicLesionsWhyshouldtreatcarotidlesion？20088CarotidArteryDiseasePatientsSymptomaticAsymptomatic25%75%CarotidStenosis20088SymptomaticCarotidStenosisNaturalHistoryCarotidstenosis+TIARiskofstrokein1styr=12-13%

5thyr=30-37%

Sundtetal.,1987 Dennisetal.Stroke,199020088AsymptomaticCarotidStenosisNaturalHistoryStenoses>75% riskofstrokein1styr=2-5%

Roedereretal.Stroke,1984

Hennerecietal.Brain,198720088Majorstrokebystenosisseverity20088Riskofstrokeinpatientswithasymptomaticcarotidstenosishasfallensignificantly.Abbottetal.,InternationalJournalofStroke,2007.20088ATROCAP：

Atorvastatin20mgStabilizeplaque“Stabilizingplaqueisanimportantmechanismtoreducecardiovascularandcerebralevents.”MeanPercentchange

（%)-60-50-40-30-20-100UlcerationInflammationMacrophagePlacebo（n=30）Lipitor20mg（n=29）CortellaroMetal.ThrombHaemost.2002;88:41-47.20088RiskStratificationofAsymptomaticCarotidStenosisEurJVascEndovascSurgxx,1e10(2008)20088Plaquemorphology：“HighRisk”20088“Vulnerable”plaqueincarotidspecimen20088Lesionmorphologiesincarotidartery20088PlaqueMorphologyandStrokeRiskUlceration=Iminentstroke riskofstroke= 7.5%

Autretetal.Lancet,1987Heterogeneousandulceratedlesions=Risk2-4x

Langsfeldetal.JVascSurg,1989

Sterpettietal.Stroke,1988

20088WhatweknownowTheriskofstrokeisrelevanttoseverityofstenosisHistologicaldatafromthecoronaryandcarotidcirculationssuggestthatotherplaquefeaturesmaybemoreimportantinpredictingfuturethrombo-embolicevents.20088RevascularizationforAsymptomaticCarotidStenosisStratificationStrategy20088

頸動脈狹窄的治療方法

20088TheCochraneCollaboration2006ASA200620088Step1：HighRiskofStrokeSevereCarotidStenosis（≥80%）+UnfavorablePlaqueFeatures

（ulcerationorheterogenecity

）20088Step2：HighRiskforStentingHighriskPatients

>80yofage(asymptomatic)AccessproblemsBaselinelargeneurologicaldefectMarkedcerebralatrophy+microangiopathyDementia/AlzheimerHighriskAnatomyObviousfillingdefect/thrombusVesselocclusion“String”sign-asymptomaticSeveredistalloops/kinks/bendsHeavyconcentriccalcificationsTypeIIIaortaarch20088Highriskforintervention20088Any2ofthefollowing=HighRiskAGE≥80↓CerebralReserveExcessiveTortuosityHeavyconcentriccalcificationCriteriaofHighRiskCarotidStenting20088ProposedNewParadigmCarotidRevascularizationIn