Endarterectomia carotidea Indicazioni nei pazienti sintomatici Filippo Sogaro

Endarterectomia carotidea
Indicazioni nei pazienti sintomatici
Filippo Sogaro
U.O.C. di Chirurgia Vascolare
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
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
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
2013 Sweden
7 days
14 days
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)
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
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
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”
• The classic 24-hour definition is misleading in that many patients
with transient <24-hour events actually have associated cerebral
• 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
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.
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
3. The desire to minimize risk by delaying surgery has to
be balanced with the increased risk of “unstable
4. Absence of scientific proof from conclusive randomized
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
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