MAGYAR ANGIOLÓGIAI ÉS ÉRSEBÉSZ TÁRSASÁG ÉVI KONGRESSZUSA Szombathelyi Angiológiai Napok Akkreditált Továbbképzô Tanfolyam

Átírás

1 Palásthy Zsolt

2 EMMI szakmai irányelv az extracranialis artéria carotis interna szűkület invazív ellátásáról Szerzők: Dr. Entz László, érsebész, Érsebészeti és Angiológiai Tagozat, fejlesztőcsoport-kapcsolattartó Dr. Palásthy Zsolt, érsebész, Angiológia és érsebészet Tagozat, társszerző Dr. Hüttl Kálmán radiológus, MACIRT, társszerző Dr. Szeberin Zoltán érsebész, MAÉT főtitkár, társszerző Dr. Gősi Gergely érsebész, MAÉT tag, társszerző, irodalomkeresés Dr. Nemes Balázs radiológus, Angiológiai és érsebészeti Tanács, társszerző, irodalomkeresés Véleményezők: Dr. Nagy Zoltán, neurológus, Neurológiai Tagozat, véleményező Dr. Csiba László, neurológus, Neurológiai Tagozat, véleményező Dr. Battyáni István, radiológus, Radiológiai Tagozat, véleményező Dr. Szikora István, radiológus, Radiológiai Tagozat, véleményező Dr. Bodosi Mihály, idegsebész, SZTE Idegsebészeti Klinika, Idegsebészet Tagozat, véleményező Dr. Fülesdi Béla, aneszteziológus, Aneszteziológiai és Intenzív Terápiás Tagozat, véleményező Megjelent: Egészségügyi Közlöny 2016/22. Érvényesség időtartama:

3 Ajánlás 17: A 4,5 óránál korábban észlelt stroke esetén lokális vagy szisztematikus thrombolysis az első teendő (A, 1). Ajánlás 18 : A 4,5 órán túli esetekben, a beteg stabilizálása esetén a beteget műtétre kell előkészíteni, amelyet 2 héten belül szükséges elvégezni (B, 1). Ajánlás 19: Ismétlődő (crescendo) TIA esetén sürgős CEA végzendő. Ilyen esetekben CAS azért nem javasolt, mert a tünetek hátterében instabil plaque szerkezet áll, amely az embolisatio okozója (C, 1). Updated Society for Vascular Surgery guidlines for management of extracranial carotid disease: executive summary. J Vasc Surg ESVS Guidelines Invasive treatment for carotid stenosis: indications, techniques. EJVES 37, Suppl

4 Enthusiasm has grown over the past several years for early and sometimes immediate revascularization (emergent, typically within first 24 hours) with CEA in patients presenting with acute stroke or with stroke in evolution Theoretical benefits bestowed by (1) removal of the source of thromboembolic debris (thereby reducing chance of recurrent events, particularly in the case of soft or ulcerated plaque) and (2) restoring normal perfusion pressure to the ischemic penumbra in the brain. Data suggest that delaying CEA may reduce the potential benefit of revascularization by exposing certain patients to greater risk of recurrent stroke (up to 9.5% in the North American Symptomatic Carotid Endarterectomy Trial). Early CEA is believed to reduce that risk. Tempering the enthusiasm for early intervention are concerns regarding transformation of ischemic infarction to hemorrhagic infarction, as well as the potential to increase edema or produce hyperperfusion syndrome from sudden restoration of normal perfusion pressure to the brain.

5 Sbarigia et al.: Early carotid endarterectomy after ischemic stroke: the results of a prospective multicenter Italian study. Eur J Vasc Endovasc Surg.2006;32: patients - patients with very large ischemic strokes or with more than two thirds of the MCA territory involved with infarction were excluded. - Mean time between onset of stroke and CEA was 1.5 days (±2 days). - Overall 30-day morbidity/mortality was 7.3% (7/96). - Most patients (85/96) demonstrated significant improvement; - only 3% developed greater deficits, - and no patients in this carefully selected cohort had hemorrhagic transformation or new cerebral infarction on CT. In another multicenter trial, Ballotta E, et al.: Carotid endarterectomy within 2 weeks of minor ischemic stroke: a prospective study. J Vasc Surg.2008;48: on 102 patients - case selection was limited to those with minor nondisabling stroke, who were neurologically stable - early or urgent CEA (eg, within 2 weeks of acute stroke presentation; median time 8 days) - None of the subjects experienced new strokes, hemorrhagic conversions, or cerebral edema.

6 Huber R et al-: Carotid surgery in acute symptomatic patients. Eur J Vasc Endovasc Surg. 2003;25: Welsh S et al.: Early carotid surgery in acute stroke: a multicentre randomised pilot study. Cerebrovasc Dis. 2004;18: Described combined stroke and death rates of 16% and 21%, respectively; their patients were more neurologically unstable, and some had complete carotid occlusion. Rerkasem K, Rothwell PM.: Systematic review of the operative risks of carotid endarterectomy for recently symptomatic stenosis in relation to the timing of surgery. Stroke. 2009;40:e564 e Review of 47 relevant studies, - High combined stroke and death rates for urgent CEA, 20.2% and 11.4%, in settings of stroke-in-evolution and crescendo TIA, respectively Conclude the following: (1) Risks of emergency CEA are high in patients with unstable neurological status; (2) this risk must be balanced against the risk of neurological deterioration on medical therapy; (3) current evidence does not support emergent CEA for such patients; (4) improvements in intensive medical therapy may allow for stabilization of such patients; and (5) prospective randomized controlled trials of emergent or urgent versus delayed revascularization in patients with unstable neurological status (acute evolving stroke or crescendo TIA) are warranted.

7 G. Tsivgoulis et al: Safety of early endarterectomy in patients with symptomatic carotid artery stenosis: an international multicenter study. European Journal of Neurology 2014, 21: A total of 165 patients with scas [ 70% AIS; 6% crescendo TIA; 8% with contralateral internal carotid artery (ICA) occlusion] underwent early CEA - crescendo TIAs and urgent ( 48 h) CEA were not associated with a higher risk of peri-procedural events. However, these findings should be interpreted in the light of the limited sample size in the two scas subgroups (nine cases of crescendo TIAs and 20 cases of urgent CEA) Elias Johansson et al.: Recurrent stroke in symptomatic carotid stenosis awaiting revascularization, Neurology 2016;86: Michael Reznik et al.: Timing of Carotid Revascularization Procedures After Ischemic Stroke; Stroke. 2017;48: ,

8 Following stroke or TIA, the degree of carotid artery stenosis should be reported using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method. People with non-disabling carotid artery territory stroke or TIA should be considered for carotid revascularisation if the symptomatic internal carotid artery has a stenosis of greater than or equal to 50% - performed in people who are neurologically stable and who are fit for surgery using either local or general anaesthetic according to the person s preference; - performed as soon as possible and within 1 week of first presentation; -deferred for 72 hours in people treated with intravenous thrombolysis; - only undertaken by a specialist surgeon in a vascular centre where the outcomes of carotid surgery are routinely audited

9 Carotid endarterectomy can be considered in selected patients with recent (< 3 months) non-disabling carotid artery territory ischaemic stroke or TIA with ipsilateral carotid stenosis measured at 50-69% (NASCET criteria) if it can be performed by a specialist team with audited practice and a very low rate (< 3%) of perioperative stroke and death. Strong Recommendation Carotid endarterectomy should be performed as soon as possible (ideally within two weeks) after the ischaemic stroke or TIA. Strong Recommendation

10 Urgent carotid endarterectomy People with stable neurological symptoms from acute non-disabling stroke who have symptomatic carotid stenosis of 50 99% according to the NASCET criteria, or 70 99% according to the ECST criteria, should: be assessed and referred for carotid endarterectomy within 1 week of onset of stroke symptoms undergo surgery within a maximum of 2 weeks of onset of stroke symptoms receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice). People with stable neurological symptoms from acute non-disabling stroke who have symptomatic carotid stenosis of less than 50% according to the NASCET criteria, or less than 70% according to the ECST criteria, should: not undergo surgery receive best medical treatment (control of blood pressure, antiplatelet agents, cholesterol lowering through diet and drugs, lifestyle advice).

11 Optimal timing for revascularization after presentation with acute stroke or TIA remains to be defined and likely will vary depending on several factors, including size of infarct, presence and size of residual penumbra, stability of neurological status, and general medical condition of the patient. Emergent CEA indications must be considered carefully for each individual patient. Recommendations: The usefulness of emergent or urgent CEA when clinical indicators or brain imaging suggests a small infarct core with large territory at risk (eg, penumbra), compromised by inadequate flow from a critical carotid stenosis or occlusion, or in the case of acute neurological deficit after CEA, in which acute thrombosis of the surgical site is suspected, is not well established (Class IIb; Level of Evidence B). (New recommendation) In patients with unstable neurological status (either stroke-in-evolution or crescendo TIA), the efficacy of emergent or urgent CEA is not well established (Class IIb; Level of Evidence B). (New recommendation)

12 Egészségügyi szakmai irányelv Az akut ischaemiás stroke diagnosztikája és kezelése A Magyar Stroke Társaság EMMI felé hivatalos eljárásra benyújtott változata április 25. Ajánlás 77. Az azonnali vagy sürgős carotis endarterectomia hatékonysága nincs kellően bizonyítva (IIb; B) olyan esetben, amikor (1) kritikus carotis stenosis vagy occlusio miatti elégtelen perfusio okoz akut stroke-ot, illetve ha (2) carotis endarterectomia után alakul ki akut neurológiai deficit. Ajánlás 78. Instabil neurológiai állapotú betegek (súlyosbodó stroke stroke-in-evolution, crescendo TIA) esetében az azonnali vagy sürgős carotis endarterectomia hatékonysága nincs kellően bizonyítva (IIb; B). Akut stroke-ban alkalmazott sürgősen elvégzett CEA-nak vagy más sürgősségi sebészeti beavatkozásnak súlyos kockázata lehet, emiatt a precíz betegbeválasztásnak kiemelt jelentősége van. A terápiás döntés egyéni mérlegelést tesz szükségessé. A revascularizáció optimális ideje még meghatározásra vár és valószínűleg több tényezőtől függ, mint pl. az infarktus kiterjedtsége, a rezidualis penumbra jelenléte és mérete, a beteg neurológiai statusának stabilitása és általános állapota. További vizsgálatok szükségesek az acut stroke-ban alkalmazott CEA hatásosságának és biztonságosságának megítélésére az egyes betegcsoportokban, valamint a CEA elvégzésének optimális időpontjára és a sürgős ellátásban betöltött szerepére vonatkozóan.