颈动脉狭窄的RCT结果解读课件

1、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

2、 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 Imp

3、ortance of the Carotid Artery DiseaseHistory of Carotid SurgeryCarotid Angiogarphy 1927Egas Moniz History of Carotid SurgeryExtracranial artery disease Intracranial lesionJames Hunt 1914Miller Fisher 1951History of Carotid SurgeryCarotid EndarterectomyFamous clinical trials for CEASymptomaticPtsYrsC

4、EADrugsNASCET1988222639%26%ESCT198130246.110.3%16.8%AsymptomaticPtsYrsCEADrugsACAS 1989166235.1%11%ACST 199331205103.8%11%Indications of CEA for symptomatic patients (NASCET, ECST)ischemic cerebral symptomsTIAamaurosis fugaxminor stroke ICA stenosis 50%periprocedural stroke and death rate 6%Early CE

5、A 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 Euro

6、pean 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 W

7、illisii, exhausted reserve capacityrapid progression of stenosisbefore major operationperiprocedural stroke and death rate3%Primary Closure vs. PatchBond,R et al. J Vasc Surg 2004;40:1126-35 Synthetic Patch vs. Venous PatchSystemic review of randomized controlled trials of patch angioplasty versus p

8、rimary closure and different types of patch materials during carotid endarterectomy Bond,R et al. J Vasc Surg 2004;40:1126-35Locoregional versus General anesthesiaInterpretation We have not shown a definite difference in outcomes between general and local anaesthesia for carotid surgery. The anaesth

9、etist 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;372:2132-42Some completed and ongoing randomized clinical trialsNameCasesAny stroke in 30 days Stroke or death

10、 in 30 daysCEA/CASCEA (%)CAS(%)CEA(%)CAS(%)Alberts112/1073.612.1NANACAVATAS253/2517.28.39.910.0SAPPHIRE167/1673.03.65.64.8EVA-3S259/2612.78.83.99.6SAPCE595/6056.17.56.57.7CaRESS254/1433.62.13.62.1CREST1250/12502.34.12.34.4ICSS858/8553.97.63.153.98The last and biggest RCT for CEA and CASConclusion:EVA-3S- patients with symptomatic, the rates of death and stroke at 1 and 6 months were lower with endarterectomy than wit