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Πόσο σίγουροι είμαστε για το όφελος της ενδαρτηρεκτομής ;

Πόσο σίγουροι είμαστε για το όφελος της ενδαρτηρεκτομής ;. Γεώργιος Ντάιος Παθολογική Κλινική & Ομώνυμο Ερευνητικό Εργαστήριο Ιατρική Σχολή Πανεπιστημίου Θεσσαλίας. Heart Vessels Stroke Α thens , 2 7 - 0 1-201 3. Disclosures.

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Πόσο σίγουροι είμαστε για το όφελος της ενδαρτηρεκτομής ;

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  1. Πόσο σίγουροι είμαστε για το όφελος τηςενδαρτηρεκτομής; Γεώργιος Ντάιος Παθολογική Κλινική & Ομώνυμο Ερευνητικό Εργαστήριο Ιατρική Σχολή Πανεπιστημίου Θεσσαλίας Heart Vessels Stroke Αthens, 27-01-2013

  2. Disclosures • Support to attend conferences: Bayer; Sanofi-Aventis; Pfizer; Lundbeck; Boehringer-Ingelheim;Bristol Myers Squibb; Galenica. • Honoraria: Quintiles; CHUV. • Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis. • National coordinator (Greece) for the ENOS trial.

  3. JAMA 1995; 273:1421-1428

  4. ACAS: Asymptomatic Carotid Artery Study 5.1% 11% JAMA 1995; 273:1421-1428

  5. Lancet 2004; 363: 1491–502

  6. ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

  7. ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

  8. Stroke 2011; 42(8):e464-540

  9. It is reasonable to perform carotid endarterectomy in asymptomatic patients with >70% internal carotid artery stenosis if the risk of perioperative stroke, MI, and death is low. (Level A, Class IIb) Stroke 2011; 42(8):e464-540

  10. ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

  11. Number-Needed-to-Treat: 40 (to prevent 1 stroke in 5 years)

  12. Best (???) medical treatment

  13. Lancet 1996; 348: 1329–39

  14. CAPRIE: Clopidogrel vs. Aspirin Lancet 1996; 348: 1329–39

  15. Lancet 2006; 367: 1665–73

  16. ESPRIT: Aggrenox vs. Aspirin Lancet 2006; 367: 1665–73

  17. Best (???) medical treatment - Better antiplateletsare available now

  18. ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

  19. ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

  20. Stroke 2008; 39: 3297–3302

  21. Stroke 2008; 39: 3297–3302

  22. Best (???) medical treatment - Better antiplatelets are available now - 30% did not receive statin

  23. Stroke 2009; 40:e573– e583

  24. ACAS: Asymptomatic Carotid Artery Study • Excellent safety record • an annual minimum of 12 carotidendarterectomies • mortality/morbidity rate <3% in the last 50 cases. • 40% of initial applicants were rejected • 2 strokes/deaths  temporarily suspended

  25. Subgroup analysis ?

  26. ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

  27. Stroke 2004; 35:2425-2427

  28. Lancet 2005; 365:176-86

  29. Lancet 2005; 365:176-86

  30. Lancet 2005; 365:176-86

  31. Subgroup analysis

  32. Risk stratification ?

  33. Degree of stenosis Stroke 2000; 31:615-621

  34. Plaque surface Stroke 2000; 31:615-621

  35. Total plaque area Stroke 2011; 42:972-978

  36. Stroke 2006; 37:818-823

  37. Radiology 2009; 252: 502-8

  38. Intraplaquehemorrhage Radiology 2009; 252: 502-8

  39. Microembolicsignals Lancet Neurol 2010; 9: 663–71

  40. Lancet Neurol 2010; 9: 663–71

  41. Microembolicsignals Lancet Neurol 2010; 9: 663–71

  42. Silent strokes J VascSurg 2009;49:902-9

  43. Silent strokes J VascSurg 2009;49:902-9

  44. Risk stratification • Degree of stenosis • Plaque surface • Total plaque area • Fibrous cap • Intraplaque hemorrhage • Microemboli • Silent strokes

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