颈动脉狭窄的RCT结果解读

颈动脉狭窄的RCT结果解读,樊雪强 叶志东 刘鹏中日友好医院心血管外科,Carotid stenosis is present in 75% of men and 62% of women 65 years OLeary DH, Polak JF, Kronmal RA, et al. Stroke 1992; 23: 1752-60 According to the American Heart Association and American Stroke Association 170,000 CEA are performed annually in the USA The risk of developing stroke within 90 days of a transient ischemie event (TIA) is 10.5 %.The mortality rate of Cardiovascular and Cerebrovascular disease was NO 1 in 2008. Johnston SC, Gress DR, Browner WS, Sidney S. JAMA 2000;284:2901 -6. WoIfPA, DAgostino RB, Kannel WB, et al. JAMA 1988;259:1025-9.,The Importance of the Carotid Artery Disease,History of Carotid SurgeryCarotid Angiogarphy 1927,Egas Moniz,History of Carotid SurgeryExtracranial artery disease Intracranial lesion,James Hunt 1914,Miller Fisher 1951,History of Carotid SurgeryCarotid Endarterectomy,Famous clinical trials for CEA,Indications of CEA for symptomatic patients (NASCET, ECST),ischemic cerebral symptomsTIAamaurosis fugaxminor stroke ICA stenosis 50%periprocedural stroke and death rate 6%,North American Symptomatic Carotid Endarterectomy Trial (NASCET),In 659 patients with a prior nondisabling stroke or TIA associated with a carotid stenosis of 70 to 99 percent, carotid endarterectomy significantly reduced the incidence of a major stroke or death at two years (p0.01).,North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1991; 325:445.,Benefit of carotid endarterectomy after recent cerebral ischemic episode,The NASCET trial included 659 patients with a recent transient ischemic attack or nondisabling stroke and a 70 to 99 percent carotid stenosis who were randomized to medical therapy or carotid endarterectomy. After a two year follow-up, the cumulative risk of any ipsilateral stroke was lower in those who underwent surgery compared to the medical group (9 versus 26 percent, p0.001).,North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1991; 325:445.,Early CEA is associated with improved outcomes,CEA is likely to be of greatest benefit if performed within two weeks of the last neurologic event in patients with 70 percent or greater carotid stenosis.,Rothwell, PM, Eliasziw, M, Gutnikov, SA, et al, Lancet 2004; 363:915.,European Carotid Surgery Trial,European Carotid Surgery Trialists Collaborative Group. Lancet 1998; 351:1379.,Among 588 patients with a symptomatic 80 to 99 percent carotid stenosis, carotid endarterectomy reduced the incidence of a major stroke (p60%additional risk factors: contralateral occlusion,incomplete circulars - arteriosus Willisii, exhausted reserve capacityrapid progression of stenosisbefore major operation,periprocedural stroke and death rate3%,ACAS trial,1662 asymptomatic ICA stenosisThe incidence of ipsilateral stroke and any perioperative stroke or death rate was significantly lower in the surgical group than with aspirin alone (5 versus 11 percent) for a relative risk reduction of 0.53 (95% CI 0.22-0.72).Subgroup analysis suggested that CEA was less effective in women. Men had an absolute risk reduction of 8% but in women was only 1.4%,ACST trial,3120 patients with 60 percent or greater asymptomatic carotid stenosisThe CEA group had a perioperative risk of stroke or death of 3.1 percent within 30 days of surgery. The five-year risk for all strokes or perioperative death in the CEA group was reduced by nearly half compared with the CEA deferral group (6.4 versus 11.8 percent ),The benefit from CEA was significant for patients younger than 75 years of age. The benefit of CEA was significant for contralateral as well as ipsilateral carotid strokes.,Thrombendarterectomy versus Eversion EndarterectomyEVEREST Trial,Primary Closure vs. Patch,Bond,R et al. J Vasc Surg 2004;40:1126-35,Synthetic Patch vs. Venous Patch,Systemic review of randomized controlled trials of patch angioplasty versus primary closure and different types of patch materials during carotid endarterectomy,Bond,R et al. J Vasc Surg 2004;40:1126-35,Locoregional versus General anesthesia,Interpretation We have not shown a definite difference in outcomes between general and local anaesthesia for carotid surgery. The anaesthetist and surgeon, in consultation with the patient, should decide which anaesthetic technique to use on an individual basis.,GALA Trial 3526 Pts. Pimary outcome: GA:4,8% LA:4,5%,Lancet 2008;372:2132-42,Management of atherosclerotic carotid artery disease: Clinical practice guidelines of the Society for Vascular Surgery J-Vasc-Surg.2008;48(2):480-6,The development of Carotid angioplasty and stenting (CAS),Effect of carotid artery stenting,Some completed and ongoing randomized clinical trials,The last and biggest RCT for CEA and CAS,Conclusion:,EVA-3S- patients with symptomatic, the rates of death and stroke at 1 and 6 months were lower with