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Estenose de Carótida

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Marco Antônio Costa Bósio

on 20 September 2012

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Transcript of Estenose de Carótida

Estenose de Carótida Anatomia Fisiologia Etiologia Epidemiologia Quadro Clínico Diagnóstico Tratamento Ponta do iceberg Doença Cerebrovascular
Extracraniana Estenose de Carótida 1ª causa de óbito - neurológica
2ª causa de óbito - cardiovascular
3ª causa de óbito - geral 150:100.000 nos EUA
impacto socioeconômico Doença Cerebrovascular
Extracraniana artérias carótidas internas artérias vertebrais 20% débito cardíaco -> fluxo sanguíneo cerebral aterosclerose arterite de Takayasu
displasia fibromuscular
aneurisma
dissecção
acotovelamento da carótida
embolia de origem cardíaca
tumores de pescoço
radioterapia estenose por
placa de ateroma
lesão inflamatória / displásica isquemia do território da carótida interna artérias da retina frontal parietal temporal amaurose fugaz homolateral
hemianopsia homolateral
cefaléia
deterioração mental sensitivo-motor contralaterais:
sensação de fraqueza / cansaço
hemiparesia / hemiplegia
déficit sensitivo hemicorpo Isquemia AIT AVC Isquemia
cerebral
generalizada perda
contínua
da função isquemia
crônica oclusões e
estenoses sintomas
súbitos <24h
sem sequelas AIT em
crescendo perda súbita
da função
neurológica sequelas
variáveis AVC em
progressão rápida recuperação / comprometimento cerebral / óbito EMERGÊNCIA
CIRÚRGICA EMERGÊNCIA
CIRÚRGICA Déficit neurológico
reversível >24 horas
sem sequelas Fisiopatologia história
exame físico
exames complementares sinais vitais -
ausculta do trajeto vascular
palpação de pulsos -
arritmias e sopros cardíacos -
exame físico neurológico
PA de membros superiores - sensibilidade e
especificidade <70% baixo débito carótida e temporal superficial cardioembólico USG Doppler
TC de crânio
Doppler transcraniano
RNM de crânio
Laboratoriais Angiografia convencional
Angiografia RNM
Angiografia TC
Oculopletismografia
Eletrocardiograma USG Doppler barato
seguro
alta sensibilidade
alta especificidade limitações
calcificações arteriais
tortuosidade arterial
bifurcação alta
pescoço curto
examinador dependente Angio Tomografia fase aguda da isquemia
diagnóstico diferencial -
identifica lesões antigas - provavelmente assintomáticas isquemia ou hemorragia relativamente seguro
fácil execução
não é examinador dependente
planejamento cirurgico
laudo 95% = arteriografia contraste iodado Angiografia Ressonância Magnética sem contraste é pouco confiável
claustrofóbico
implantes metálicos baixo risco
confiável com contraste
extensão da imagem Oculopletismografia (OPG) diferença de pressão intraocular e braquial Doppler transcraniano Arteriografia invasivo
contraste iodado
risco de 1% AVE em indivíduos com doença cerebrovascular maior acurácia
padrão ouro
angioplastia / stent / trombólise princípio de Bernoulli
efeito de Venturi
lei de Poiseuille
coeficiente de Reynolds
reação de Cushing
estenose >90% Laboratoriais hemograma
eletrólitos
uréia
creatinina TAP
TTPa
perfil lipídico Eletrocardiograma diferencial de causa cardioembólica
diagnóstico de IAM ou isquemia miocárdica maior causa de morte na endarterectomia maior incidência de doença coronariana Aterosclerose Fatores de risco
idade
HAS
sopro carotídeo
DM
tabagismo FA
obesidade
dislipidemia
níveis elevados de homocisteína 90% Estenose (grego stenos = estreitamento)
Artéria (grego aerterion = duto de ar)
Carótida (grego karos = sono profundo) Histórico 1793 - Hebenstreit:
1805 - Sir Astley Cooper:
1914 - Ramsay Hunt:
1927 - Egas Moniz:
1951 - Carrea, Molins e Murphy:

1953 - Michael Debakey:
1954 - Eastcott: ligadura de carótida ligadura de carótida por aneurisma cervical correlacionou a estenose com isquemia cerebral arteriografia cerebral anastomose de carótida externa para interna distal à estenose endarterectomia Classificação 1975: anatomia, tempo, mecanismo de desenvolvimento,
patologia, clínica e estado neurológico CHAT: Current Status; History; Arterial lesion; target organ Sociedade de Cirurgia Vascular Americana
Sociedade Internacional de Cirurgia Cardiovascular a - Assintomático
b - AIT
c - AVC reversível
d - AVC permanente
e - AIT crescendo - AVC em evolução assintomáticos sintomáticos estudos ECST, NASCET e VAST estenose carotídea >50% = cirurgia estudo ACAS (Asymptomatic Carotid Atherosclerosis Study) ? assintomáticos estudos CASANOVA, Mayo Trial,
VA Asymphtomatic Trial e ACAS estenose <50% estenose de 50 a 70% estenose >70% tratamento clínico antiagregante plaquetário (AAS, clopidogrel)
controle dos fatores de risco: hipertensão
obesidade
fumo
hiperlipidemia tratamento cirúrgico 15% terão AVC em 3 anos
maior parte deles em 6 meses indicação da cirurgia depende dos fatores: idade do paciente
características da placa
habilidade da equipe cirúrgica há uma tendência em não indicar cirurgia para este grupo depende <35 anos - 3,5:100.000
>85 anos - 1800:100.000 1 a cada 56 reconstrução da carótida oclusão de grande artéria do pescoço oclusão de pequena artéria cerebral vs Etiologia AVC fatores intracranianos trombose
hemorragia
vasoespasmo mecanismo hemodinâmico mecanismo trombogênico acentuado em baixo débito
isquemia cerebral difusa
fluxo cerebral no PO igual ulceração da placa
hemorragia intraparietal
trombose da artéria vertebrais História Natural progressão da placa estabilizar progredir 38% 62% oclusão total ulceração
hemorragia
dissecção subintimal silenciosa
ou
sintomática obrigado Juliana Libman Luft
Marco Antônio Costa Bósio Estenose de Carótida Annambhotla S
Não houve diferença entre o seguimento de 30 dias e longo prazo entre intervenção precoce e endarterectomia posterior.
Em estenose de carótida sintomática com evidência de hemorragia intracraniana, oclusão de carótida ou alteração neurológica permanente, a endarterectomia precoce pode ser seguramente realizada, e deve ser preferida à postergar cirurgia. Habersberger J
Stent é uma alternativa para endarterectomia.
O tratamento cirúrugico deve ser comparado com o tramento clínico otimizado em pacientes assintomáticos. Xu J
Stent pode ser efetivo para restaurar a estenose em pacientes idosos e prevenir ocorrência de AVC.
Idosos, DM, ICC tem maior probabilidade de aumentar risco de eventos adversos no pós-operatório. Bonati LH
Tratamento endovascular associado com aumento do risco de AVC e óbito perioperatório, principalmente em pacientes mais idosos. Spirin NN
Endarterectomia diminuiu a progressão da isquemia cerebral crônica, estabilizando ou melhorando o status neurológico ou neuropsicológico. Sfyroeras GS
Cirurgia híbrida tem índices de AVC e óbitos igual ou menores que endarterectomia. Zhonghua Wai Ke Za Zhi. 2012 Jun;50(6):534-8.
[Article in Chinese]
Xu J, Wang J, Li BM, Li S, Cao XY, Liu XF.
Source: Department of Neurosurgery, Chinese People's Liberation Army General Hospital, Beijing 100853, China.
Abstract
OBJECTIVES: To evaluate the risk factors and safety of carotid angioplasty and stenting(CAS) for extracranial carotid stenosis in elderly patients and summarize CAS on the indication of elderly patients and the prevention of complications.
METHODS: The population characteristics, clinical features and vascular data of 60 elderly patients (≥ 75 years) treated between June 2001 and December 2010 were retrospectively analyzed. There were 57 male and 3 female. The median age of the patients was 78.8 years (range, 75 - 93 years ). The mean case history was 2.5 months with a range of 1 to 6 months. To summarize the prognosis of CAS according to the reduction ofstenosis, NIHSS score, the incidence of early postoperative, 30 days adverse events and the follow-up status. Using χ(2) test as the statistical method.
RESULTS: The mean stenosis was reduced from 81% ± 17% preoperative to 18% ± 9% postoperative. NIHSS score was reduced from preoperative 22 ± 8 to postoperative 10 ± 4. The average follow-up period was 1.5 years (range from 3 months to 3 years), and the results showed no procedure-related death occurred. Ipsilateral stroke occured in 1 case (1.7%) and restenosis (≥ 50%) occurred in 2 patients (3.3%). Diabetes (χ(2) = 23.96, P < 0.01)and cardiac insufficiency (χ(2) = 6.446, P < 0.05)had a respectively significant impact on the incidence of early postoperative complications.
CONCLUSIONS: CAS can be effective in restoring carotid artery stenosis of elderly patients and preventing the occurrence of stroke. The eld, diabetes, cardiac insufficiency are more likely to increase the postoperative risk of adverse events. [Risk factors in carotid angioplasty and stenting for extracranial carotid stenosis of elderly patients]. Gahremanpour A
Endarterectomia e stent foram associadas a óbito e AVC.
Em 30 dias, estenose de carótida foi associada com maior risoc de IAM.
Tratamento endovascular deve ser uma alternativa, sempre considerando idade do paciente e anatomia, risco cirúrgico, experiência do cirurgião. J Vasc Surg. 2011 Aug;54(2):534-40.
Sfyroeras GS, Karathanos C, Antoniou GA, Saleptsis V, Giannoukas AD.
Source: Department of Vascular Surgery, University Hospital of Larissa, Larissa, Greece. gsfyr@yahoo.gr
Abstract
OBJECTIVE: High grade stenoses of both the innominate (IA) or common carotid artery (CCA) and the carotid bifurcation are rare and represent a therapeutic dilemma for the treating physician. A hybrid procedure with concomitant carotid endarterectomy (CEA) and retrograde angioplasty has been proposed as a less invasive treatment option. The aim of this study is to review the existing literature on such hybrid procedures.
METHODS: An electronic search of the pertinent English literature was undertaken. A meta-analysis of all studies reporting on simultaneous carotidendarterectomy and retrograde angioplasty for the treatment of tandem internal carotid and proximal common carotid or innominate artery lesions was performed.
RESULTS: Thirteen studies, including 133 patients were identified. Sixty-eight percent of the patients were male, 83% symptomatic. Proximal lesions were located in ipsilateral CCA in 85 cases and in IA in 48 cases. Reported technical success of the procedure was 97%. In 79 of the 129 successful operations, a stent was implanted, while the remaining 50 patients underwent simple balloon angioplasty. Thirty-day mortality and stroke rate were 0.7% and 1.5%, respectively. Combined 30-day mortality and stroke rate was 1.5%. During a mean follow-up of 12 to 36 months, five patients presented symptoms of cerebral ischemia and 17 died. Ten patients developed restenosis of the proximal lesion, (4 symptomatic, 7 in cases without stent) and 2 restenoses of the endarterectomy (all asymptomatic). Restenosis was treated in 7 cases (4 repeat angioplasty, 3 bypass grafts).
CONCLUSIONS: This meta-analysis reports the largest collection of patients having undergone hybrid treatment of tandem disease of the arch vessels and carotid bifurcation. Results from this study show that the combined stroke and death rate with this approach is equal to or better than that for isolated endarterectomy. When possible, balloon angioplasty with stenting of the proximal component of this disease should be pursued to avoid restenosis. A meta-analysis of combined endarterectomy and proximal balloon angioplasty for tandem disease of the arch vessels and carotid bifurcation. J Vasc Surg. 2012 Aug 1. [Epub ahead of print]
Annambhotla S, Park MS, Keldahl ML, Morasch MD, Rodriguez HE, Pearce WH, Kibbe MR, Eskandari MK.
Source: Northwestern University Feinberg School of Medicine, Chicago, Ill.
Abstract
BACKGROUND: Delayed carotid endarterectomy (CEA) after a stroke or transient ischemic attack (TIA) is associated with risks of recurrent neurologic symptoms. In an effort to preserve cerebral function, urgent early CEA has been recommended in many circumstances. We analyzed outcomes of different time intervals in early CEA in comparison with delayed treatment.
STUDY DESIGN: Retrospective chart review from a single university hospital tertiary care center between April 1999 and November 2010 revealed 312 patients who underwent CEA following stroke or TIA. Of these 312 patients, 69 received their CEA within 30 days of symptom onset and 243 received their CEA after 30 days from symptom onset. The early CEA cohort was further stratified according to the timing of surgery: group A (27 patients), within 7 days; group B (17), between 8 and 14 days; group C (12), between 15 and 21 days; and group D (12), between 22 and 30 days. Demographic data as well as 30-day (mortality, stroke, TIA, and myocardial infarction) and long-term (all-cause mortality and stroke) adverse outcome rates were analyzed for each group. These were also analyzed for the entire early CEA cohort and compared against the delayed CEA group.
RESULTS: Demographics and comorbid conditions were similar between groups. For 30-day outcomes, there were no deaths, 1 stroke (1.4%), 0 TIAs, and 0 myocardial infarctions in the early CEA cohort; in the delayed CEA cohort, there were 4 (1.6%), 4 (1.6%), 2 (0.8%), and 2 (0.8%) patients with these outcomes, respectively (P > .05 for all comparisons). Over the long term, the early group had one ipsilateral stroke at 17 months and the delayed group had two ipsilateral strokes at 3 and 12 months. For long-term outcomes, there were 16 deaths in the early CEA cohort (21%) and 74 deaths in the delayed CEA cohort (30%, P > .05). Mean follow-up times were 4.5 years in the early CEA cohort and 5.8 years in the delayed CEA cohort.
CONCLUSINS: There were no differences in 30-day and long-term adverse outcome rates between the early and delayed CEA cohorts. In symptomatic carotid stenosis patients without evidence of intracerebral hemorrhage, carotid occlusion, or permanent neurologic deficits early carotidendarterectomy can be safely performed and is preferred over delaying operative treatment. Early vs delayed carotid endarterectomy in symptomatic patients. Curr Opin Cardiol. 2012 Aug 30. [Epub ahead of print]
Habersberger J, Brott TG, Roubin GS.
Source: aAtherothrombosis and Vascular Biology Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia bDepartment of Neurology, Mayo Clinic, Jacksonville, Florida cCardiology Division, Department of Medicine, NYU Langone Medical Center, New York, USA.
Abstract
PURPOSE OF REVIEW: Carotid endarterectomy (CEA) has been shown to prevent stroke in patients with severe carotid stenosis. Carotid artery stenting (CAS) has emerged as a less invasive alternative technique. Data regarding comparative effectiveness of CAS and CEA are now available and merit review.
RECENT FINDINGS: Four large randomized controlled trials (RCTs) comparing CAS and CEA have shown a higher rate of stroke in symptomatic patients. The largest and most recent trial reported a lower occurrence of myocardial infarction (MI) following CAS and showed overall comparability of CAS to CEA for both symptomatic and asymptomatic patients. Despite methodological differences, these RCTs are consistent in finding an interaction of patient age with outcomes. In younger patients, CAS appears equivalent or superior to CEA if considering the sum of death, stroke, and MI. In elderly patients, CEA appears to have a lower complication rate. For asymptomatic patients, reduction in event rates with current medical therapy may render previous trial results invalid.
SUMMARY: CAS is an alternative to CEA in patients requiring carotid intervention. Comparison of both CAS and CEA with contemporary medical management will also be required before recommendations can be made regarding the optimal treatment of patients with asymptomatic carotidstenoses. Carotid artery stenting: a clinical update. Tex Heart Inst J. 2012;39(4):474-87.
Gahremanpour A, Perin EC, Silva G.
Source: Division of Cardiology, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Texas 77030.
Abstract: For about 2 decades, investigators have been comparing carotid endarterectomy with carotid artery stenting in regard to their effectiveness and safety in treating carotid artery stenosis. We conducted a systematic review to summarize and appraise the available evidence provided by randomized trials, meta-analyses, and registries comparing the clinical outcomes of the 2 procedures. We searched the MEDLINE, SciVerse Scopus, and Cochrane databases and the bibliographies of pertinent textbooks and articles to identify these studies.The results of clinical trials and, consequently, the meta-analyses of those trials produced conflicting results regarding the comparative effectiveness and safety of carotid endarterectomy andcarotid stenting. These conflicting results arose because of differences in patient population, trial design, outcome measures, and variability among centers in the endovascular devices used and in operator skills. Careful appraisal of the trials and meta-analyses, particularly the most recent and largest National Institutes of Healthsponsored trial (the Carotid Revascularization Endarterectomy vs Stenting Trial [CREST]), showed that carotidstenting and endarterectomy were associated with similar rates of death and disabling stroke. Within the 30-day periprocedural period, carotidstenting was associated with higher risks of stroke, especially for patients aged >70 years, whereas carotid endarterectomy was associated with a higher risk of myocardial infarction. The slightly higher cost of stenting compared with endarterectomy was within an acceptable range by cost-effectiveness standards. We conclude that carotid artery stenting is an equivalent alternative to carotid endarterectomy when patient age and anatomy, surgical risk, and operator experience are considered in the choice of treatment approach. Carotid Artery Stenting versus Endarterectomy: A Systematic Review. MAIN RESULTS: We included 16 trials involving 7572 patients. In patients with symptomatic carotid stenosis at standard surgical risk, endovascular treatment was associated with a higher risk of the following outcome measures occurring between randomisation and 30 days after treatment than endarterectomy: death or any stroke (the primary safety outcome) (OR 1.72, 95% CI 1.29 to 2.31, P = 0.0003; I(2) = 27%), death or any stroke or myocardial infarction (OR 1.44, 95% CI 1.15 to 1.80, P = 0.002; I(2) = 7%), and any stroke (OR 1.81, 95% CI 1.40 to 2.34, P < 0.00001;I(2) = 12%). The OR for the primary safety outcome was 1.16 (95% CI 0.80 to 1.67) in patients < 70 years old and 2.20 (95% CI 1.47 to 3.29) in patients ≥ 70 years old (interaction P = 0.02).The rate of death or major or disabling stroke did not differ significantly between treatments (OR 1.28, 95% CI 0.93 to 1.77, P = 0.13; I(2) = 0%). Endovascular treatment was associated with lower risks of myocardial infarction (OR 0.44, 95% CI 0.23 to 0.87, P = 0.02; I(2) = 0%), cranial nerve palsy (OR 0.08, 95% CI 0.05 to 0.14, P < 0.00001; I(2) = 0%) and access site haematomas (OR 0.37, 95% CI 0.18 to 0.77, P = 0.008; I(2) = 27%).The combination of death or any stroke up to 30 days after treatment or ipsilateral stroke during follow-up (the primary combined safety and efficacy outcome) favoured endarterectomy (OR 1.39, 95% CI 1.10 to 1.75, P = 0.005; I(2) = 0%), but the rate of ipsilateral stroke after the peri-procedural period did not differ between treatments (OR 0.93, 95% CI 0.60 to 1.45, P = 0.76; I(2) = 0%).Restenosis during follow-up was more common in patients receiving endovascular treatment than in patients assigned surgery (OR 2.41, 95% CI 1.28 to 4.53, P = 0.007; I(2) = 55%). In patients with asymptomatic carotid stenosis, treatment effects on the primary safety (OR 1.71, 95% CI 0.78 to 3.76, P = 0.18; I(2) = 0%) and combined safety and efficacy outcomes (OR 1.75, 95% CI 0.92 to 3.33, P = 0.09; I(2) = 0%) were similar to symptomatic patients, but differences between treatments were not statistically significant. Among patients not suitable for surgery, the rate of death or any stroke between randomisation and end of follow-up did not differ significantly between endovascular treatment and medical care (OR 0.22, 95% CI 0.01 to 7.92, P = 0.41; I(2)= 79%).
AUTHORS' CONCLUSIONS: Endovascular treatment is associated with an increased risk of peri-procedural stroke or death compared with endarterectomy. However, this excess risk appears to be limited to older patients. The longer term efficacy of endovascular treatment and the risk of restenosis are unclear and require further follow-up of existing trials. Further trials are needed to determine the optimal treatment for asymptomaticcarotid stenosis. Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis. ochrane Database Syst Rev. 2012 Sep 12;9:CD000515.
Bonati LH, Lyrer P, Ederle J, Featherstone R, Brown MM.
Source: Department ofNeurology,UniversityHospital Basel, Basel, Switzerland. martin.brown@ucl.ac.uk.
Abstract
BACKGROUND: Endovascular treatment by transluminal balloon angioplasty or stent insertion may be a useful alternative to carotid endarterectomy for the treatment of atherosclerotic carotid artery stenosis. This review updates a previous version first published in 1997 and subsequently updated in 2004 and 2007.
OBJECTIVES: To assess the benefits and risks of endovascular treatment compared with carotid endarterectomy or medical therapy in patients with symptomatic or asymptomatic carotid stenosis.
SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched January 2012) and the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 4), MEDLINE (1950 to January 2011), EMBASE (1980 to January 2011) and Science Citation Index (1945 to January 2011). We also searched ongoing trials registers (January 2011) and reference lists and contacted researchers in the field.
SELECTION CRITERIA: Randomised trials comparing endovascular treatment (including balloon angioplasty or stenting) with endarterectomy or medical therapy for symptomatic or asymptomatic atherosclerotic carotid stenosis.
DATA COLLECTION AND ANALYSIS: One review author selected trials for inclusion, assessed trial quality and extracted data. A second review author independently validated trial selection and a third review author independently validated data extraction. We calculated treatment effects as odds ratios (OR) and 95% confidence intervals (CI), with endovascular treatment as the reference group. We quantified heterogeneity using the I(2) statistic. Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis. Zh Nevrol Psikhiatr Im S S Korsakova. 2012;112(6):40-44.
[Article in Russian]
Spirin NN, Malyshev NN, Malysheva IV.
Source: Kafedra nervnykh bolezneĭ s meditsinskoĭ genetikoĭ i neĭrokhirurgieĭ Iaroslavskoĭ gosudarstvennoĭ meditsinskoĭ akademii.
Abstract: We examined 127 patients with atherosclerotic stenosis of carotid arteries who underwent carotid endarterectomy (CEAE). In the most of patients (85%), CEAE slowed the progression of chronic cerebral ischemia leading to the stabilization or improvement of neurologic and/or neuropsychological status. The analysis of the data allowed to suggest a mathematical model for predicting the outcome of the surgery. [The assessment of prognosis of carotid endarterectomy by cliniсal-mathematical method.] Período intra-operatório:
embolização de placa aterosclerótica;

Período pós-operatório:
trombose carotídea;
lesão de nervos hipoglossos, facial, vago, auricular magno e cervical transverso;
reestenose da carótida,
hematomas cervicais,
infecção cirúrgica. Tratamento Cirúrgico – Complicações A) Colocação de fio guia em artéria carótida interna.
B, C) Posicionamento do stent.
D) Balão para expansão do stent.

CCA = Artéria Carótida Comum;
ECA = Artéria Carótida Externa;
ICA = Artéria Carótida Interna. Endovascular - Stent Endarterectomia
Endovascular Tratamento Cirúrgico Indicações de Revascularização A) Um filtro foi posicionado na Artéria Carótida Interna (ICA). 
B) Um balão inflado na ICA. 
C) Balões inflados na Artéria Carótida Externa (ECA) e Artéria Carótida Comum (CCA). Dispositivos de proteção à embolia A) Dissecção da artéria carótida. 
B) Remoção da placa aterosclerótica.
C) Fechamento da artéria carótica with a patch.

CCA = Artéria Carótida Comum;
ECA = Artéria Carótida Externa;
ICA = Artéria Carótida Interna. Endarterectomia Indicações de Revascularização Assintomáticos Sintomáticos Contra-indicações
ao Tratamento Cirúrgico
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