Endarterectomia carotidea Indicazioni nei pazienti sintomatici Filippo Sogaro U.O.C. di Chirurgia Vascolare Trento Società Triveneta di Chirurgia 29 novembre 2013 – Este (PD) The first successful carotid reconstruction was performed by Carrera et al. in 1951 in a male patient suffering from stroke. During this procedure, they cut out the stenosed area of the proximal internal carotid artery and made an end-to-end anastomosis using the transected proximal portion of the external carotid artery to the internal carotid artery. Carrea R, Molins M, Murphy G. Surgical treatment of spontaneous thrombosis of the internal carotid artery in the neck. Carotid-carotideal anastomosis. Report of a case. Acta Neurol Latinoamer. 1955;1:71-8. Trial Clinici Randomizzati Stenosi carotidee sintomatiche per TIA o minor stroke 1991: NASCET (N Engl J Med) & ECST (Lancet) la correzione chirurgica della stenosi carotidea(60%-99%) è il trattamento più efficace per ridurre il rischio di stroke nei pazienti sintomatici 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/ SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: CEA had a similar benefit for symptomatic patients across both trials and for both men and women. Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease: executive summary. J Vasc Surg 2011;54:832-6 Studio SPREAD-STACI, SICVE, http://www.sicve.it, SPREAD, http://www.spread.it, The Italian STROKE FORUM Carotide Sintomatica e TEA : Riduzione del rischio ictus ipsi-laterale a 5 anni Rothwell PM, et al. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004;363:915-24. Rischio cumulativo di stroke dopo TIA o minor stroke • Il rischio di stroke nella settimana che segue un TIA o minor stroke è elevato, fino oltre il 10% Coull AJ, et al. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. BMJ 2004;328:326 Johnston SC, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007;369:283-92. Risk of early recurrent stroke in TIA patients with an ipsilateral 50%-99% carotid stenosis First author year country Faithead 2005 UK Purroy 2007 Spain Ois 2009 Spain Johannson 2013 Sweden 48h 72h 7 days 14 days - - - 20% 10% 17% 5% 22% 25% 8% 11% Johansson EP, Arnerlov C, Wester P: Risk of recurrent stroke before carotid endarterectomy. The ANSYSCAP Study. Int J Stroke 2013; 8:220-7 Ois A, Quadrado-Godia E, Rodriguez-Campello A, Jmenez-Conde J, Roquer J: High risk of early neurological recurrence in symptomatic carotid stenosys. Stroke, 2009; 40, 2727- 31. Stenosi carotidea sintomatica: TIMING dell’intervento? 4-6 week delay prior to surgery (Stroke 2002;33:1057-1062) Within 14 days of symptom onset (ESVS Guidelines: 2009) Early CEA performed in the weeks or DAYS after symptom onset (reasonable option unless contraindicated: AHA, 2011) Symptomatic patients should undergo CEA <48 hours of symptom (National strategy for stroke: UK – 29 april 2013) onset Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease: executive summary. J Vasc Surg 2011;54:832-6 R Sharpe, RD Sayers, NJM London, MJ Bown, MG McCarty, A Nasim, RSM Davis, AR Naylor. Procedural risk following carotid endarterectomy. ESVS Journal 2013; 46, 5, 519-24) Salem MK, et al. Eur J Vasc Endovasc Surg 2011;41:222-8 Maggiore rischio chirurgico nelle TEA in urgenza: SwedVasc - Audit 2012 Urgent carotid endarterectomy confers increased procedural risk: CEA performed 0 to 2 days after the qualifying event was associated with a 4-fold higher procedural risk compared with surgery performed at 3 to 7 days Very Urgent Carotid Endarterectomy Confers Increased Procedural Risk: S Stromberg; J Gelin; Osterberg; G M.L. Bergstrom; L Karlstrom; K. Osterberg: ; for the Swedish Vascular Registry (Swedvasc) Steering Committee. Stroke 2012 43 1221-5 Maggiore rischio chirurgico nelle TEA in urgenza: Review 2009 Rerkasem et al. Stroke 2009;40:e564-e572 Rischio chirurgico nelle TEA in urgenza: Outcomes of urgent carotid endarterectomy for stable and unstable acute neurologic deficits TIA group Mild-Moderate Stroke group Stroke in evolution group no postoperative stroke 5,8% postoperative stroke 27,3% postoperative stroke Urgent-CEA (48 h from deficit onset) was safe when performed on patients presenting with transient ischemic attack. An acceptable complication rate was achieved for patients with minor to moderate strokes. The poorest outcomes occurred in patients presenting with stroke in evolution: Urgent-CEA in these patients should be offered with extreme caution, although we are aware that a conservative treatment may not grant a better prognosis. Iacopo Barbetta, MD, Michele Carmo, MD, Giulio Mercandalli, MD, Patrizia Lattuada, MD, Daniela Mazzaccaro, MD, Alberto M. Settembrini, MD, Raffaello Dallatana, MD, Piergiorgio G. Settembrini, MD. 2013 J Vasc Surg nov 16 Risultati contrastanti da evidente difformità nel reclutamento dei pazienti definiti “sintomatici” Problemi aperti: •Uniformità dell’inquadramento clinico •La valutazione strumentale del danno cerebrale •Identificazione della placca a rischio •Consenso sui molti “score predittivi” TIA • The classic 24-hour definition is misleading in that many patients with transient <24-hour events actually have associated cerebral infarction. • The definition of TIA requires brain imaging, CT and MRI (depending on the availability of imaging resources) • MRI is more sensitive than standard CT in identifying both new and preexisting ischemic lesions in TIA patients. Across various studies, MRI has shown at least 1 infarct somewhere in the cerebrum in 46% to 81% of TIA patients Definition and Evaluation of Transient Ischemic Attack: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease: The American Academy ofNeurology affirms the value of this statement as an educational tool for neurologists. J. Donald Easton, Jeffrey L. Saver, Gregory W. Albers, Mark J. Alberts, Seemant Chaturvedi, Edward Feldmann, Thomas S. Hatsukami, Randall T. Higashida, S. Claiborne Johnston, Chelsea S. Kidwell, Helmi L. Lutsep, Elaine Miller and Ralph L. Sacco. Stroke 2009 MRI: DWI - PWI a) Perfusion-weighted image 4 hours after onset of stroke symptoms (Rankin 4) and before revascularization displays a perfusion deficit (red and green) of the right hemisphere, which represents “tissue at risk” for further infarction. b) Perfusion-weighted image taken 1 week after successful revascularization of the right internal carotid artery demonstrates a perfusion deficit in the area of the definitive infarction (green), while the surrounding tissue recovered (blue). Clinic for Vascular Surgery and Kidney Transplantation, University Hospital of Düsseldorf, Heinrich-Heine-University of Düsseldorf, Düsseldorf, Germany - Symptomatic acute occlusion of the internal carotid artery: Reappraisal of urgent vascular reconstruction based on current stroke imaging Presented at the 2007 Vascular Annual Meeting, Baltimore, Md, Jun 6-10, 2007. Border-zone Stroke Infarti “emodinamici” • Stroke di tipo emodinamico (giunzionali, watershed, border-zone) responsabile del 19-64% di tutti gli ictus • Poligono di Willis incompleto • Occlusione carotidea controlaterale • Scompenso cardiaco • Aterosclerosi intracranica/scadente collateralità Jean-Baptiste E, Perini P, et al. Eur J Vasc Endovasc Surg 2013;45:210-7 Momjian-Mayor I, Baron JC. Stroke 2005 CT and CTA CT-identified leukoaraiosis was associated with an increased risk of stroke in a mixed group of TIA and stroke patients with 50% to 99% internal carotid artery stenosis Contra-indications to surgery are extensive established infarction on CT-scan (more than 1/3 of the middle cerebral artery territory) Inclusion of arterial and parenchymal imaging with CT angiography (CTA) can rapidly provide useful information that may influence management and may indicate infarct size, location, and extent of vessel occlusion and collateral integrity, all of which can influence clinical outcome Computed Tomography Angiography in Hyperacute Ischemic Stroke Prognostic Implications and Role in Decision-Making Considerazioni sul timing Linee guida SVS (USA 2011) – NICE (National Institute for Health and Care Excellence - UK 2013) • Carotid surgery is recommended as early as possible (within 2 weeks) for patients with TIA, minor stroke or mild stabilized neurological deficit, with normal CT scan or minimal lesions • In patients “fit for surgery” • With a 50%-99% (NASCET) 60%-99% (ECST)carotid stenosis Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease: executive summary. J Vasc Surg 2011;54:832-6 Nice Guideline 68 Stroke: diagnosis and initial management of acute stroke and TIA. April 2013 SPREAD (2012) In caso di stenosi carotidea sintomatica superiore al 50% (equivalente a metodo NASCET) è indicata l’endoarteriectomia precoce, cioè entro le prime due settimane dall’evento ischemico minore. E’ presumibile che l’endoarteriectomia offra il massimo beneficio se eseguita nei primi giorni dal sintomo, probabilmente entro 48 ore dal sintomo, e in ogni caso alla stabilizzazione dell’evento ischemico cerebrale. The Italian STROKE FORUM E nei pazienti neurologicamente “instabili” ? 1. There is a lack of a consensus definition of c-TIA and unstable stroke (fluctuating stroke, progressive stroke, or stroke-in-evolution) 2. Absolute contraindications to surgery vary among authors 3. The desire to minimize risk by delaying surgery has to be balanced with the increased risk of “unstable patients” 4. Absence of scientific proof from conclusive randomized trials Come muoversi? La TEA carotidea in paziente neurologicamente instabile è decisione collegiale, in Centri di esperienza, supportata da adeguato neuroimaging encefalico e dei vasi cerebroaffrenti. Richiede l’identificazione dell’area di penombra ischemica e della vulnerabilità della placca oltre che dell’entità della stenosi. Presuppone un team precostituito, in grado di gestire anche in urgenza la decisione. Sono raccomandati criteri cut-off: NIHSS non sup. a 6, lesione cerebrale ischemica inferiore a 2,5 cm e non superiore a 1/3 del territorio della acm, coscienza conservata. Indicato l’uso dello shunt e il monitoraggio intraoperatorio (TC doppler). L’intervento in urgenza presuppone competenza anestesiologica specifica e il decorso postoperatorio in TI o Stroke Unit