无症状的颈动脉狭窄的介入治疗应该分情况对待英文课件.ppt

GDPPH, JF LuoIntervention for Asymptomatic Carotid Stenosis should be Stratified 罗建方 广东省人民医院 Jianfang Luo, M.D. Guangdong Cardiovascular Institute Guangdong Provincial People’s HospitalGDPPH, JF LuoThe mechanism of stroke with carotid lesion• Emboli • Hypoperfusionn nClinical symptoms caused by embolic disease in > 80% of patientsn 75% risk of stroke in 1st yr = 2-5%Roederer et al. Stroke, 1984Hennereci et al. Brain, 1987GDPPH, JF LuoMajor stroke by stenosis severityGDPPH, JF LuoRisk of stroke in patients with asymptomatic carotid stenosis has fallen significantly.Abbott et al., International Journal of Stroke, 2007.GDPPH, JF LuoATROCAP：Atorvastatin 20mg Stabilize plaque“Stabilizing plaque is an important mechanism to reduce cardiovascular and cerebral events.”Mean Percent change （%)-60-50-40-30-20-100UlcerationInflammationMacrophagePlacebo（n=30）Lipitor20mg（n=29）Cortellaro M et al. Thromb Haemost. 2002;88:41-47.GDPPH, JF LuoRisk Stratification of Asymptomatic Carotid StenosisEur J Vasc Endovasc Surg xx, 1e10 (2008)GDPPH, JF LuoPlaque morphology：“High Risk” GDPPH, JF Luo“Vulnerable” plaque in carotid specimenGDPPH, JF LuoLesion morphologies in carotid arteryGDPPH, JF LuoPlaque Morphology and Stroke Risk• Ulceration = Iminent stroke risk of stroke = 7.5%Autret et al. Lancet, 1987• Heterogeneous and ulcerated lesions = Risk 2-4 x Langsfeld et al. J Vasc Surg, 1989Sterpetti et al. Stroke, 1988 GDPPH, JF LuoWhat we know now• The risk of stroke is relevant to severity of stenosis• Histological data from the coronary and carotid circulations suggest that other plaque features may be more important in predicting future thrombo-embolic events. GDPPH, JF LuoRevascularization for Asymptomatic Carotid StenosisStratification StrategyGDPPH, JF Luo颈动脉狭窄的治疗方法颈动脉狭窄的治疗方法 1．药物治疗 （Medical Therapy）2．颈动脉内膜剥离术 （Carotid Endarterectomy, CEA）3．经皮颈动脉支架植入术（Carotid Artery Stenting, CAS）GDPPH, JF LuoThe Cochrane Collaboration 2006ASA 2006GDPPH, JF LuoStep 1 ：High Risk of Stroke• Severe Carotid Stenosis （≥80%）+ • Unfavorable Plaque Features（ulceration or heterogenecity ）GDPPH, JF LuoStep 2 ：High Risk for StentingHigh risk Patients• >80 y of age (asymptomatic) •Access problems •Baseline large neurological defect •Marked cerebral atrophy + microangiopathy •Dementia / Alzheimer High risk Anatomy •Obvious filling defect / thrombus •Vessel occlusion •“String” sign - asymptomatic •Severe distal loops/kinks/bends •Heavy concentric calcifications •Type III aorta archGDPPH, JF LuoHigh risk for interventionGDPPH, JF LuoAny 2 of the following = High RiskAGE ≥ 80↓Cerebral ReserveExcessive TortuosityHeavy concentric calcificationCriteria of High Risk Carotid StentingGDPPH, JF LuoProposed New ParadigmCarotid Revascularization Indicated?YesNoHigh Stent RiskYesNoMedical Management SurveillanceCEA if low riskCarotid StentNeed good training Don’t forget optimal medical therapy !GDPPH, JF LuoThank you !。