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P.Teutonico U.O. Chirurgia Vascolare ed Endovascolare interaziendale Cesena-forlì

P.Teutonico U.O. Chirurgia Vascolare ed Endovascolare interaziendale Cesena-forlì Ospedale “ M.Bufalini ” di Cesena - Morgagni Pierantoni di Forlì. “RISULTATI DELL’ ENDOARTERECTOMIA CAROTIDEA NELLA SINDROME CEREBROVASCOLARE ACUTA ”.

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P.Teutonico U.O. Chirurgia Vascolare ed Endovascolare interaziendale Cesena-forlì

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  1. P.Teutonico U.O. Chirurgia Vascolare ed Endovascolare interaziendale Cesena-forlì Ospedale “M.Bufalini” di Cesena-MorgagniPierantoni di Forlì “RISULTATI DELL’ ENDOARTERECTOMIA CAROTIDEA NELLA SINDROME CEREBROVASCOLARE ACUTA ”

  2. Coull AJ, Lovett JK, Rothwell PM. Population based study of early risk after TIA or minor stroke. BMJ 2004; 328: 326-329 Rischio comulativo di stroke dopo TIA o stroke minore Rothwell PM. Transient ischaemic attacks: time to wake up. Heart 2007;93:893-894 Rothwell PM, Eliasziw M, Gutnikov SA, et al. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet. 2003;361:107–16.

  3. Rothwell PM, Eliasziw M, Gutnikov SA, Fox AJ, Taylor DW, Mayberg MR. Carotid edarterectomy trialists’ collaboration. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 2003;361:107-6. Rerkasem K., Rothwell P.M.Systematic Review of the Operative Risks of Carotid Endarterectomy for Recently Symptomatic Stenosis in Relation to the Timing of Surgery Stroke. 2009;40:e564-e572) A.R. Naylor Eur J Vasc Endovasc Surg 35, 383-391(2008)

  4. ATTIVITA’ CHIRURGICA EAC/CAS 629 EAC dal 2005 TOT:1035 267 EAC+139 CAS dal 2006

  5. EAC TOTALI Cesena: 629 EAC Forlì:267 EAC TOT:896 +

  6. EAC SINTOMATICHE≤ 14 gg 81 SINTOMATICI (TIA, Minor Stroke)

  7. CRITERI DI ESCLUSIONE ● NIHSS ≥ 5 ● Sintomatologia neurologica instabile (crescendo TIA, Stroke in evolution) ● Occlusione dell’a. cerebrale media ● Lesioni ischemiche > 2,5 cm alla Tc/RM encefalo

  8. RISULTATI TIA/AFX 40,74% (33/81) MINOR STROKE 59,26% (48/81) 22/48 (45,8%) NIHSS 1-3 26/48 (54,2%) NIHSS 4 2,95 ±1,03

  9. RISULTATI Età 71±10 aa (55-91) Sesso M 60,4% (49/81) Ipertensione 85,1% (69/81) Diabete mellito 22,2% (18/81) ACOP 21,65 (13/60) CAD 30,8%(25/81) Dislipidemia 71,06% (58/81) BPCO 28,3% (23/81) Occlusione ICA control. 6,1% (5/81) Stenosi emodin. ICA control. 6,1% (5/81)

  10. DIAGNOSTICA PREOPERATORIA TC/RM encefalo positiva ≥ 2cm 37,5% (18/48) Stenosi ≥ 50-69% 21/81 pz (26,2%) Placca ipo-anecogena 15/21 (71.4%) Placca ipo-anecogena 6/21 (28,6%) Stenosi ≥70% -99% 65/81 pz (80,2%) Stenosi preocclusiva 4/81 pz (4,9%)

  11. TIMING CHIRURGICO (gg) TIA/AFX 25 pz 2±1,2(range0-4 gg) MINOR STROKE 35 pz 4,8±2,1(range2-10 gg)

  12. TECNICA ANESTESIOLOGICA 12 pz (14,8%) Anestesia Locale 69 pz (85,2%) Anestesia Generale

  13. TECNICA CHIRURGICAshunting Anestesia Locale 4 pz (33,3%) Stump Pressure< 50 mmHg (range 21-47 mmHg) Stump Pressure< 50 mmHg 30 pz (43,4%) Anestesia generale 69 pz (100%)

  14. CEREBRAL CIRCULATORY SUPPORTShunting . .Shunting is needed in approximately 10% to 15% Gumerlock MK, Neuwelt EA. Carotid endarterectomy: to shunt or notto shunt. Stroke 1988;19:1485-90. Ferguson GG. Carotid endarterectomy. To shunt or not to shunt? Arch Neurol 1986;43:615-7. There is no evidence for the routine use of shuntduring CEA (A) Both methods are acceptable,individual surgeons should select the method with they are more comfortable

  15. RISULTATI 80,2% (65 pz) 94,5±19,6 min 18,6% (15 pz) 85,5±10,3 min 1,2% (1 pz)

  16. Degenza post-operatoria TIA/AFX 3,2± 1,1 gg (range 2-5 gg) MINOR STROKE 5,6±2,5 gg (range4-12 gg)

  17. RISULTATI PERIOPERATORI % pz Mortalità globale 2,4% (2/81) (Mortalita neurlogica 1,2%) Recidiva ictus 2,4% (2/81) (peggioramento NIHSS 5≥7 gruppo MS) Miglioramento NIHSS 30 (62,5%) Revisione chirurgica 1,2% (1/81) Lesione NC 3,7% (3/81)

  18. RISULTATI PERIOPERATORI % pz Mortalità globale 2,4% (2/81) (Mortalita neurlogica 1,2%) Recidiva ictus 2,4% (2/81) (peggioramento NIHSS 5≥7 gruppo MS) Miglioramento NIHSS 30 (62,5%) Revisione chirurgica 1,2% (1/81) Lesione NC 3,7% (3/81)

  19. RISULTATI PERIOPERATORI % pz Mortalità globale 2,4% (2/81) (Mortalita neurlogica 1,2%) Recidiva ictus 2,4% (2/81) (peggioramento NIHSS 5≥7 gruppo MS) Miglioramento NIHSS 30 (62,5%) Revisione chirurgica 1,2% (1/81) Lesione NC 3,7% (3/81) (2 n. l.sup;1 n.ipoglos.)

  20. RISULTATI A DISTANZA (12 MESI) pz Mortalità globale 4 (Mortalita neurlogica 1,2%) Recidiva ictus 1 Ostruzione dell’ICA 2 Revisione chirurgica 1 (Ematoma latero-cerv in TAO) Stenosi emodinamiche 0 (≥ 70% NASCET)

  21. Conclusioni Capoccia L, Sbarigia E, Speziale F, Toni D, Fiorani P. Urgent carotid endarterectomy to prevent recurrence and improve neurologic out come in mild-to-moderate acute neurologic events. J VAsc Surg 2011;53:622-8. Dorigo W, Pulli R, Nesi M, Alessi Innocenti A, Pratesi G, Inzitari D, Pratesi C. Urgent Carotid Endarterectomy in patients with recent/crescendo TIA or acute stroke. Eur J Vasc Endovasc Surg 2011;41:351-357. • Annambhotla S., Park S., Keldahl L., Morasch MD., Rodriguez HE., Pearce WH., Kibbe MR., Eskandari MK. Early versus delayed carotid endarterectomy in symptomatic patients J Vasc Surg 2012;56:1296-302

  22. Easton JD., Saver L., Albers GW., Alberts M.J., Chaturved S., Feldmann E., Hatsukami TS., Higashida RT., Johnston SC., Kidwell CS., Lutsep HL., Miller E., Sacco RL Definition and Evaluation of Transient Ischemic Attack. A Scientific Statement for Healthcare Professionals From the AmericanHeart Association/American Stroke Association Stroke Council; Council onCardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiologyand Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease Stroke. 2009;40:2276-2293 Ischemic Penumbra &”Time is Brain”

  23. EAC < 48 h Sbarigia E, Toni D, Speziale F, Acconcia MC, Fiorani P. Early carotid endarterectomy fter ischemic stoke: the results of a prospective multicenter Italian study.Eur J Vasc Endovasc Surg 2006; 32:29-235. Capoccia L, Sbarigia E, Speziale F, Toni D, Fiorani P. The need for emergency surgical treatment in carotid-related stroke in evolution and crescendo TIA. J Vasc Surg 2012; 55:1611-77.

  24. TROMBOLISI e EAC

  25. Post-fibrinolisi Ostruzione ICA dx

  26. PERCORSO STROKE M. Aleksic et Al. Primary Stroke Unit Treatment Followed by Very Early Carotid Endarterectomy for Carotid Artery Stenosis after Acute Stroke Cerebrovasc Dis 2006;22:276–281 31

  27. “Time is Brain” GRAZIE

  28. TECNICA CHIRURGICAaccesso

  29. National Institute of Neurological Disorders and Stroke Stroke and Trauma Division. North American Symptomatic Carotid Endarterectomy Trial (NASCET) Investigators. Clinical alert: benefit of carotid endarterectomy for patients with high-grade stenosis of the internal carotid artery. Stroke. 1991;22:816 –7. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70–99%) or with mild (0–29%) carotid stenosis. European Carotid Surgery Trialists’ Collaborative Group. Lancet. 1991;337:1235–1243.

  30. • receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice). Diagnosis and initial management of acute stroke and transient ischaemic attack 1.2.4 Urgent carotid endarterectomy and carotid stenting 1.2.4.1 People with stable neurological symptoms from acute non-disabling stroke or TIA should: • be assessed and referred for carotid endarterectomy within 1 week of onset of stroke or TIA symptoms undergo surgery within a maximum of 2 weeks of onset of stroke or TIA symptoms 35 NICE clinical guideline 68 – 2008

  31. The National StrokeStrategy UK DepartementofHealth, 5th december 2007 “Carotid intervention for recently symptomatic, severe carotid stenosis should be regarded as a emergency procedure in patients who are neurologically stable, and should ideally be performed within 48 hoursof a transient ischemic attack or minor stroke Jonston SC. RothwellPM et Al. Validation and refinement of scores to predict very early stroke risk after TIA Lancet 2007;369:283-92

  32. Stroke 2009; 40: 564-572 Eur J Vasc Endovasc Surgery 2009; 37,504-511 Per quanto riguarda il rischio di complicanze importanti legate all’intervento, di cui bisogna comunque tener conto nella valutazione del beneficio chirurgico, è noto che nel paziente con TIA o ictus minore, la CEA eseguita nella prima settimana dal sintomo se il paziente è neurologicamente stabile e la CEA dilazionata presentano un rischio pressoché identico.

  33. RISULTATI A DISTANZA 2005/Maggio 2011

  34. According to those studies, surgery had to be dlayed for at least 4 weeks from the neurologic event because of the risk of hemorragic transformation of the acute brain ischemic lesion.

  35. Carotid patch angioplasty was associated with: • a reduction in the risk of stroke of any type • ipsilateral stroke • stroke or death during the peri-operative period and long-term follow-up • a reduced risk of perioperative arterial occlusion and decreased re-stenosis during long-term follow-up in five trials (78)

  36. EVEREST (multicenter randomized trial): • The 30-day perioperative major stroke/ death rates were similar for both groups (1.3%). • The 30-dayall stroke rates were also similar (2.2% for eversion CEA vs 1.9% for conventional CEA). • At a mean follow-up of 33 months, carotid restenosis was noted in 2.8% with eversion CEA vs 7.9% with primary closure and 1.5% for CEA with patch closure. • The cumulative carotid restenosis at 4 years was lower in the eversion CEA, compared to the primary closure group (3.6% vs 9.2%), however, this difference in restenosis disappeared when eversion CEA was compared to CEA with patch angioplasty (2.8% vs 1.5%).

  37. Proper positioning of the patient is necessary to provide optimal exposure of the neck from the clavicle up to the mastoid process on the side of the proposed operation. Excessive neck extension should be avoided, however, because it places tension on the artery and actually hinders rather than facilitates exposure. This potential problem can be addressed by placing one or more towels under the head to adjust the neck to the optimal degree of extension. The patient's head is then turned away from the side of the operation to improve cervical exposure further. The head of the table may be elevated slightly if the patient's blood pressure is adequate; this step helps lower venous pressure and reduce venous bleeding during the operation. The more common choice is a vertical incision placed along an imaginary line that extends from the sternoclavicular junction to the mastoid process, paralleling the anterior margin of the sternocleidomastoid muscle as well as the course of the carotid artery and the contents of the carotid sheath. The incision is centered over the presumed location of the carotid bifurcation. The advantage of this incision is that it provides optimal exposure of the cervical carotid artery and can readily be extended either proximally or distally along the aforementioned imaginary line to give additional exposure when needed (e.g., when the carotid bifurcation is unusually high). The disadvantage of this incision is that it runs against Langer's lines; thus, if a keloid occurs, it is likely to be in an unsightly position. . The internal jugular vein is usually the most visible vessel, The common facial vein, which drains into the internal jugular vein, is a relatively constant landmark. On occasion, a patient has several accessory facial veins instead of a single common facial vein. The common facial vein or the accessory facial veins are then divided between ligatures so that the jugular vein can be retracted laterally. The common carotid artery and the carotid bifurcation lie immediately beneath the divided facial veins.

  38. At this point, care must be taken to look for the vagus nerve. This nerve is usually located posterior to the common carotid artery, but it is sometimes rotated into a more superficial position. Another important neurologic structure in this area is the ansa cervicalis, which is formed by the junction of fibers from the hypoglossal (12th cranial) nerve and fibers from the first cervical nerve and which continues inferiorly as a single trunk. This nerve should be spared if possible, but it can be divided without significant sequelae if it interferes with optimal exposure of the carotid bifurcation. One convenient method of separating the nerve from the artery is to divide the fibers running from the first cervical nerve to the ansa cervicalis; when this is done, the nerve is readily mobilized and retracted anteriorly away from the carotid artery

  39. Next, dissection is continued distally beyond the bulb of the internal carotid artery to a point where the internal carotid artery is normal. At this point, the relevant portion of [see Figure 5]. Once this is accomplished, the external carotid artery is mobilized beyond the end point of plaque extension in a similar manner A common error in carotid artery mobilization is failure to recognize that the plaque in the internal carotid artery extends beyond the upper limit of the arterial exposure. It is far better to anticipate this problem before clamping and opening the artery than to discover it afterward and be forced to mobilize the vessel after it has been clamped. Once the common carotid and internal carotid arteries have been mobilized sufficiently, they are encircled.

  40. PREMESSE The National Institute for Clinical Excellence recommendation that all patients should be treated < 2 weeks of onset symptoms has been superseded by the United Kingdom Department of Health recommendation that EAC should be regarded as an emergency procedure in stable symptomatic patients and should ideally be performed < 48 hours of a TIA or MINOR STROKE(27,28)

  41. PREMESSE A meta-analysis of recent studies published in 2007 observed that the risk of stroke after a TIA or MINOR STROKE was: • 6,7% at 2 days • 10,4% at 7 days Thus reporting much higher values than previously accepted.(24)

  42. PREMESSE Atherosclerosis from supra-aortic vessels and especially from the common carotid bifurcation is a major cause of recurrent ischaemic stroke, accounting for approximately 20% of all strokes, while nearly 80% of these may occur without warning, thus emphasisingthe need for careful patient follow up (7,8,9,10)

  43. PREMESSE Ischaemic stroke rapresent a major health problem and is an important cause of long term disability in several developed countries. (1,2,3) Mortality for stroke ranges between 10% and 30%, and its survivors remain at a high annual risk of recurrent ischaemic events and mortality, both from myocardial infarction and repeated stroke.(5,6)

  44. INTRODUCTION A surgeon must stay within the accepted perioperative stroke rate of < 7% for symptomatic carotid artery stenosis: * < 5% for TIAs * < 7% for STROKE as recommended by the Ad Hoc Committee of the Stroke Council of the AHA Moore WS, Barnett HJ, Beebe HG, Bernstein EF, Brener BJ, Brott T, et al. Guidelines for carotid endarterectomy. A multidisciplinary consensus statement for the Ad Hoc Committee, American Heart Association. Circulation 1995;91:566-79.

  45. N 560 H R 228 Caratteristiche dei pazienti Fattori di rischio fisiologici Maschi 55% 63% ETA’>80 anni 80 Bianchi 95% 98% IMA < 6 mesi 11 Fumo 73% 80% Ipertensione 80% 76% NYHA III/IV angina 16 CANADIAN CHF III/IV 4 Sintomatici 38% 43% BPCO cortisonici/O2 4 Fattori di rischio anatomici Creatininemia > 3 13 OCCLUSIONE C/L 66 RESTENOSI 29 LESIONI DISTALI 53 COLLO IRRADIATO 3 High-Risk carotid endarterectomy: Fact or fiction A.P. Gasparis, J.J. Ricotta J Vasc Surg 2003 … Patients with significant medical comorbidities, controlateral carotid occlusion, and high carotid lesion can undergo operation without increased complications… …The concept of the high risk CEA must be critically reexamined…

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