無癥狀的頸動脈狹窄的介入治療應該分情況對待-英文ppt課件

1、GDPPH, JF LuoIntervention for Asymptomatic Carotid Stenosis should be Stratified 羅建方羅建方 廣東省人民醫(yī)院廣東省人民醫(yī)院Jianfang Luo, M.D.Jianfang Luo, M.D.Guangdong Cardiovascular InstituteGuangdong Cardiovascular InstituteGuangdong Provincial PeopleGuangdong Provincial Peoples Hospitals HospitalGDPPH, JF LuoThe mec

2、hanism of stroke with carotid lesion Emboli HypoperfusionGDPPH, JF LuoPosteriorInferiorCerebellarArteryInternalCarotidArteryVertebralArteryAthroscleroticplaqueThrombusEmbolusOcclusivethrombusCerebral Circulation andThromboembolic LesionsWhy should treat carotid lesion？GDPPH, JF LuoCarotid StenosisGD

3、PPH, JF LuoSymptomatic Carotid Stenosis Natural History Carotid stenosis + TIA Risk of stroke in 1st yr = 12-13% 5th yr = 30-37% Sundt et al., 1987 Dennis et al. Stroke, 1990GDPPH, JF LuoAsymptomatic Carotid Stenosis Natural History Stenoses 75%risk of stroke in 1st yr = 2-5% Roederer et al. Stroke,

4、 1984 Hennereci 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, 2019.GDPPH, JF LuoATROCAP： Atorvastatin 20mg Stabilize plaque“Stabilizin

5、g plaque is an important mechanism to reduce cardiovascular and cerebral events.Mean Percent change %)-60-50-40-30-20-100UlcerationInflammationMacrophagePlacebon=30Lipitor20mgn=29Cortellaro M et al. Thromb Haemost. 2019;88:41-47.GDPPH, JF LuoRisk Stratification of Asymptomatic Carotid StenosisEur J

6、Vasc Endovasc Surg xx, 1e10 (2019)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

7、 Heterogeneous and ulcerated lesions = Risk 2-4 x Langsfeld et al. J Vasc Surg, 1989 Sterpetti 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

8、be more important in predicting future thrombo-embolic events. GDPPH, JF LuoRevascularization for Asymptomatic Carotid StenosisStratification StrategyGDPPH, JF Luo1藥物治療 Medical Therapy2頸動脈內膜剝離術 Carotid Endarterectomy, CEA3經皮頸動脈支架植入術 Carotid Artery Stenting, CAS GDPPH, JF LuoThe Cochrane Collaboratio

9、n 2019 ASA 2019GDPPH, 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 problemsBaseline large neurological defectMarked cerebral atro

10、phy + microangiopathyDementia / Alzheimer High risk AnatomyObvious filling defect / thrombusVessel occlusion“String sign - asymptomatic Severe distal loops/kinks/bends Heavy concentric calcificationsType III aorta archGDPPH, JF LuoHigh risk for interventionGDPPH, JF LuoAny 2 of the following = High RiskAGE 80Cerebral ReserveExcessive TortuosityHeavy concentric calcificationCriteria of High Risk Carotid StentingGDPPH, JF LuoProposed New ParadigmCarotid Revascularization Indic