2. Enfermedad Carotídea
Prevalencia
Población general : 5% de enfermedad
carotídea.
Duplica el riesgo de Episodios Cerebro
Vasculares
3. Prevalencia
El Stroke es precedido de un AIT
En 10% de los casos en estudios comunitarios.
15 al 35% de los casos en base a datos
hospitalarios
Friedman et. Al, JAMA 1969, Whisnant et al. Mayo Clin proc 1973, Herman et al Stroke 1982
4. Enfermedad
Carotídea.
Se estima que la Enfermedad Carotídea
extacraneana es responsable de mas del 30% de
los strokes.
La enfermedad estenosante de la arteria carótida
por placas de arteroma tiene alta prevalencia
apartir de los 50 años.
La progresión de esta enfermedad se ve
favorecida por la presencia de FRCV (sexo masc,
edad, DBT, DLP, TBQ, hiperhomocisteinemia).
10. Examen clínico-neurológico
completo
Presentación clásica:
Debilidad de cara y brazo contralateral que en
ocasiones puede afectar la pierna
Alteraciones mono oculares transitorias.
Síntomas no asociados:
Síncope, mareo, vértigo, alt sensitivas de brazo o
alteraciones cognitivas.
11. Revascularización Carotídea. Cómo?
Estudio neurológico completo
Stroke
– Perfusión Cerebral - Estudio de Perfusión .
- Acople o match P-D - Estudio de Viabilidad.
12. CORRELACION
DIFUSIÓN/PERFUSION
ACOPLE (MATCH)
DESACOPLE (MISMATCH)
Con un desacople del 49%, el beneficio fue
muy bueno;
Con uno del 28%, la evolución fue
favorable;
Con menos del 15%, no hubo beneficio;
Con menos del 8%, la evolución fue
desfavorable.
Trombo ACP
DEFUSE STUDY Albers GW et al
Ann Neurol 2006;60:508-517
13. Estudios de Perfusión-difusión.
Cómo?
La correlación volumétrica entre D-P, la denominamos
acople o match a la falta de acople mist match.
Una lesión en Difusión menor que la Perfusión, representa
menor daño bioenergético que oligohémico., mayor
beneficio con trombolisis.
Imágenes acopladas entre D-P aumentan la probabilidad de
infarto
14. Revascularización Carotídea. Cómo?
TAC
Debemos conocer la anatomía de las
estructuras cerebrales que queremos
tratar.
Evaluar parenquima normal, edema,
infartos, tumores,etc.
45. Enfermedad Carotídea Sintomática
Estenosis carotídea 70 a 79% a 2 años riesgo de ACV 20%
Estenosis carotídea 80 a 89% a 2 años riesgo de ACV 28%
Estenosis carotídea 90 a 99% a 2 años riesgo de ACV 35%
Riesgo promedio a 2 años 26%
47. Enfermedad Carotídea Sintomática
Beneficio a favor de la Endarterectomía vs.
tratamiento médico
En estenosis mayor o igual al 50%
48. Enfermedad Carotídea Sintomática
Estenosis 70 a 99% hubo un mayor
beneficio con Endarterectomía.
Estenosis 50 a 69% menor beneficio en
ACV-Muerte. (RR 10.1% a 5 años)
La Endarterectomía no esta indicada en lesiones menores al
50%
49. Pacientes Asintomáticos
ACAS Lesiones mayores al 60%
Seguimiento 2,5 años Estimacion Kaplar Mayer para evolución a 5 años.
Pacientes Asintomáticos: n 1662
ACV ipsil o muerte hosp 11.1 vs 5.1% p 0.004
Disminución de riesgo absoluto anual de 2 a 1%
RR hombres 66% RR mujeres 17%
Carótida Sintomática estenosis 70-99% : ACV o Muerte 5.7% a 10% anual
Postendarterectomía Riesgo 1% anual.
50. Metanálisis
Pacientes con estenosis asintomáticas >60% mostraron:
ACV muerte a 10 y 15 años 9.3 y 16.3%
IAM y muerte vascular a 15 años 25%
Esfuerzo en prevención del IAM y muerte
vascular
52. Endovascular versus surgical treatment in patients with
carotid
stenosis in the Carotid and Vertebral Artery Transluminal
Angioplasty Study (CAVATAS):
53. Endovascular versus surgical treatment in patients with carotid
stenosis in the Carotid and Vertebral Artery Transluminal
Angioplasty Study ( CAVATAS):
Estudio ramdomizado, multicéntrico Angioplastia vs.cirugía
en estenosis carotidea y vertebral.
504 pacientes. 251 Ang y 253 para tratamiento quirurgico.
26% stent , ninguno protección !!!
Sintomáticos (96% en ambos grupos) 6 meses previos a ramdomización.
La incidencia de eventos mayores a los 30 días no fue significativa entre en
tratamiento endovascular y cirugía
Neuropatia craneal fue reportada en 22 pts (8,7%) con cirugía pero no con
tratamiento endovascular.
Un año después de segmimiento estenosis severa ipsilateral (70-99%) fue
más común en tto endovascular 25 pts (14%) vs 7 (4%).
El tratamiento endovascular no tuvo diferencias significativas en la
incidencia de eventos a 3 años.
54. (SAPPHIRE)
Angioplastia con Stent y Protección en pacientes de
alto riesgo de endarterectomia
N= 334 ptes Lesiones>50% sintomáticos
Lesiones>80% Asintomáticos
70% eran Asintomáticos
30% Sintomáticos.
End point: Muerte Stroke Infarto
Ptes de alto riesgo: insuficiencia cardíaca, endarterectomía previa
con reestenosis, terapia de radiación previa o cirugía de cuello,
mayores de 80 años, angina de pecho, baja F Eyección, indicación
de revasc coronaria.
Yadav JS et al. N Engl J Med 2004; 351:1493-1501
55. SAPPHIRE: Three-year results
End point Carotid Carotid
stenting endarterectomy
Prespecified major secondary 41 45
end point (n)
Cumulative incidence (%) 24.6 26.9
Kaplan-Meier estimate (%) 26.2 30.3
Stroke (n) 15 15
Ipsilateral stroke (n) 11 9
Gurm HS et al. N Engl J Med 2008; 358:1572-1579.
56. CONCLUSIONES
SAPPHIRE:
La tasa del punto primario final (muerte, ACV o infarto de miocardio)
dentro de 30 días fue 39% menor entre los pacientes que fueron a
stent carotídeo con protección cerebral.
No hubo diferencias significativas entre ambos grupos con respecto
al riesgo de stroke u otro evento mayor a tres años.
57. Metanálisis
SAPPHIRE, CAVATAS, WALLSTENT
Morbimortalidad
Angioplstia es de 9,3%
Endarterectomía 9%
Diferencia no significativa
59. EVA:3S
• n=527 (262 endart, 267 stent)
• Enf carotídea 60% Sintomático
Objetivo: punto primario evaluar incidencia de stroke y
muerte periprocedimiento y a 30 días post procedimiento.
Punto secundario combinó la evaluación de stroke
periprocedimiento o muerte y stroke ipsilateral a 4 años de
seguimiento.
60. Resultados: EVA 3S
• la incidencia de stroke o muerte periprocedimineto y stroke ipsilateral
a 4 años fue mayor para el grupo de stenting carotideo que con la
endarterectomia
• (11·1% vs 6·2%, hazard ratio [HR] 1·97, 95% CI 1·06—3·67; p=0·03).
• La mayor incidencia de stroke o muerte fue periprocedimiento y a 30
días post procedimiento.
• En el seguimiento a 4 años la incidencia de stroke ipsilateral fue
similar para ambos grupos. Stroke o muerte periprocedimiento
• HR 1·77 (1·03—3·02; p=0·04, cualquier stroke o muerte HR 1·39 (0·96—2·00; p=0·08).
published in the October 19, 2006 issue of the New
England Journal of Medicine
61. SPACE Y EVA-3S
Ninguno de los dos estudios incluyó ptes de alto riesgo o
asintomáticos.
Eva-3S el 92% usó protección cerebral, en SPACE sólo el
27% usó protección cerebral.
La experiencia del operador en el EVA 3S, solo requería un
médico con al menos 5 procedimientos previos (implante de
stent) para participar en el estudio o ningún procedimiento
pero bajo la dirección de algún tutor.
63. Carotid artery stenting compared with endarterectomy in
patients with symptomatic carotid stenosis (International
Carotid Stenting Study): an interim analysis of a randomised
controlled trial Lancet 2010; 375: 985–97
Published Online
February 26, 2010
International Carotid Stenting Study investigators*
64. We compared the safety of carotid artery stenting vs endarterectomy.
Methods The International Carotid Stenting Study (ICSS) is a multicentre, international, randomised controlled trial
with blinded adjudication of outcomes. Patients with recently symptomatic carotid artery stenosis were randomly
The primary outcome
measure of the trial is the 3-year rate of fatal or disabling stroke in any territory,
which has not been analysed yet. The
main outcome measure for the interim safety analysis was the 120-day rate of stroke, death, or procedural myocardial
infarction.
Findings The trial enrolled 1713 patients (stenting group, n=855; endarterectomy group, n=858).
The incidence (120 day) of stroke,
death, or procedural myocardial infarction was 8·5% in the
stenting group compared with 5·2% in the endarterectomy group (72 vs 44 events; HR 1·69,
1·16–2·45, p=0·006). Risks of any stroke (65 vs 35 events; HR 1·92, 1·27–2·89) and all-cause death (19 vs seven
events; HR 2·76, 1·16–6·56) were higher in the stenting group than in the endarterectomy group. T hree procedural
myocardial infarctions were recorded in the stenting group, all of which were fatal, compared with four, all non-
fatal, in the endarterectomy group. There was one event of cranial nerve palsy in the stenting group compared
with 45 in the endarterectomy group. There were also fewer haematomas of any severity in the stenting group
than in the endarterectomy group (31 vs 50 events; p=0·0197).
Interpretation Completion of long-term follow-up is needed to establish the effi cacy of carotid artery stenting compared
with endarterectomy. In the meantime, carotid endarterectomy should remain the treatment of choice for patients
65. Carotid artery stenting compared with endarterectomy in
patients with symptomatic carotid stenosis (International
Carotid Stenting Study): an interim analysis of a randomised
controlled trial Lancet 2010; 375: 985–97 Published Online
February 26, 2010
International Carotid Stenting Study investigators*
Summary
Background Stents are an alternative treatment to carotid endarterectomy for symptomatic carotid stenosis, but
previous trials have not established equivalent safety and effi cacy. We compared the safety of carotid artery stenting with
that of carotid endarterectomy.
Methods The International Carotid Stenting Study (ICSS) is a multicentre, international, randomised controlled trial
with blinded adjudication of outcomes. Patients with recently symptomatic carotid artery stenosis were randomly
assigned in a 1:1 ratio to receive carotid artery stenting or carotid endarterectomy. Randomisation was by telephone call
or fax to a central computerised service and was stratifi ed by centre with minimisation for sex, age, contralateral occlusion,
and side of the randomised artery. Patients and investigators were not masked to treatment assignment. Patients were
The primary outcome
followed up by independent clinicians not directly involved in delivering the randomised treatment.
measure of the trial is the 3-year rate of fatal or disabling stroke
in any territory, which has not been analysed yet. The
main outcome measure for the interim safety analysis was the 120-day rate of stroke, death, or procedural myocardial
infarction. Analysis was by intention to treat (ITT). This study is registered, number ISRCTN25337470.
Findings The trial enrolled 1713 patients (stenting group, n=855; endarterectomy group, n=858). Two patients in the
stenting group and one in the endarterectomy group withdrew immediately after randomisation, and were not included
in the ITT analysis. Between randomisation and 120 days, there were 34 (Kaplan-Meier estimate 4·0%) events of disabling
stroke or death in the stenting group compared with 27 (3·2%) events in the endarterectomy group (hazard ratio [HR]
1·28, 95% CI 0·77–2·11). The incidence of stroke, death, or procedural myocardial infarction was 8·5% in the stenting
group compared with 5·2% in the endarterectomy group (72 vs 44 events; HR 1·69, 1·16–2·45, p=0·006). Risks of any
stroke (65 vs 35 events; HR 1·92, 1·27–2·89) and all-cause death (19 vs seven events; HR 2·76, 1·16–6·56) were higher in
the stenting group than in the endarterectomy group. Three procedural myocardial infarctions were recorded in the
stenting group, all of which were fatal, compared with four, all non-fatal, in the endarterectomy group. There was one
event of cranial nerve palsy in the stenting group compared with 45 in the endarterectomy group. There were also fewer
haematomas of any severity in the stenting group than in the endarterectomy group (31 vs 50 events; p=0·0197).
Interpretation Completion of long-term follow-up is needed to establish the effi cacy of carotid artery stenting compared
with endarterectomy. In the meantime, carotid endarterectomy should remain the treatment of choice for patients
suitable for surgery.
66. ICSS: 120-day interim safety results
End point Stenting Carotid Hazard ratio p
group, n (%) endarterectomy
group, n (%) (95% CI)
Disabling stroke 34 (4.0) 27 (3.2) 1.28 (0.77–2.11) 0.34
or death
Stroke, death, or 72 (8.5) 44 (5.2) 1.69 (1.16–2.45) 0.006
procedural MI
Any stroke 65 (7.7) 35 (4.1) 1.92 (1.27–2.89) 0.002
All-cause death 19 (2.3) 7 (0.8) 2.76 (1.16–6.56) 0.017
International Carotid Stenting Study investigators. Lancet 2010;
available at: http://www.thelancet.com.
67. Carotid artery stenting compared with endarterectomy in
patients with symptomatic carotid stenosis (International
Carotid Stenting Study): an interim analysis of a randomised
controlled trial Lancet 2010; 375: 985–97 Published Online
February 26, 2010
International Carotid Stenting Study investigators*
Summary
Background Stents are an alternative treatment to carotid endarterectomy for symptomatic carotid stenosis, but
previous trials have not established equivalent safety and effi cacy. We compared the safety of carotid artery stenting with
that of carotid endarterectomy.
Methods The International Carotid Stenting Study (ICSS) is a multicentre, international, randomised controlled trial
with blinded adjudication of outcomes. Patients with recently symptomatic carotid artery stenosis were randomly
assigned in a 1:1 ratio to receive carotid artery stenting or carotid endarterectomy. Randomisation was by telephone call
or fax to a central computerised service and was stratifi ed by centre with minimisation for sex, age, contralateral occlusion,
and side of the randomised artery. Patients and investigators were not masked to treatment assignment. Patients were
followed up by independent clinicians not directly involved in delivering the randomised treatment. The primary outcome
measure of the trial is the 3-year rate of fatal or disabling stroke in any territory, which has not been analysed yet. The
main outcome measure for the interim safety analysis was the 120-day rate of stroke, death, or procedural myocardial
infarction. Analysis was by intention to treat (ITT). This study is registered, number ISRCTN25337470.
Findings The trial enrolled 1713 patients (stenting group, n=855; endarterectomy group, n=858). Two patients in the
stenting group and one in the endarterectomy group withdrew immediately after randomisation, and were not included
in the ITT analysis. Between randomisation and 120 days, there were 34 (Kaplan-Meier estimate 4·0%) events of disabling
stroke or death in the stenting group compared with 27 (3·2%) events in the endarterectomy group (hazard ratio [HR]
1·28, 95% CI 0·77–2·11). The incidence of stroke, death, or procedural myocardial infarction was 8·5% in the stenting
group compared with 5·2% in the endarterectomy group (72 vs 44 events; HR 1·69, 1·16–2·45, p=0·006). Risks of any
stroke (65 vs 35 events; HR 1·92, 1·27–2·89) and all-cause death (19 vs seven events; HR 2·76, 1·16–6·56) were higher in
the stenting group than in the endarterectomy group. Three procedural myocardial infarctions were recorded in the
There was one
stenting group, all of which were fatal, compared with four, all non-fatal, in the endarterectomy group.
event of cranial nerve palsy in the stenting group compared with 45 in the
endarterectomy group. There were also fewer haematomas of any severity in the stenting group than in the endarterectomy group (31 vs 50 events; p=0·0197).
Interpretation Completion of long-term follow-up is needed to establish the effi cacy of carotid artery stenting compared
with endarterectomy. In the meantime, carotid endarterectomy should remain the treatment of choice for patients
suitable for surgery.
68.
69.
70. CREST
Carotid Revascularization Endarterectomy
Versus Stenting Trial
2502 pacientes
1321 sintomáticos y 1181 asintomáticos.
117 centros de US y Canadá.
-Estenosis Sintomática >50% por angiografía o >70% por
TAC/RNM.
-Estenosis Asintomáticos con lesión >60% por angiografía, >70%
por ultrasonido y >80% por TAC/RNM.
-Evalua cualquier stroke, muerte o IM, periprocedimiento y
seguimiento de stroke ipsilateral a 4 años.
71.
72. CREST: Primary, secondary and
safety end points
End point CAS CEA Hazard ratio p
(95%CI)
Primary end point <4 y 7.2 6.8 1.11 (0.81–1.51) 0.51
Primary end point: Peri- 5.2 4.5 1.18 (0.82–1.68) 0.38
procedural components
Periprocedural stroke and MI
Any periprocedural stroke 4.1 2.3 1.79 (1.14–2.82) 0.01
Periprocedural major stroke 0.9 0.7 1.35 (0.54–3.36) 0.52
Periprocedural MI 1.1 2.3 0.50 (0.26–0.94) 0.03
Cranial nerve palsies 0.3 4.8 0.07 (0.02–0.18) 0.0001
Ipsilateral stroke after 2.0 2.4 0.94 (0.50–1.76) 0.85
periprocedural period <4 y
CAS=carotid artery stenting
CEA=carotid endarterectomy
Brott TG et al. American Stroke Association International Stroke
Conference 2010; February 26, 2010; San Antonio, TX.
73.
74. CREST
Conclusión:
A 30 días el riesgo de stroke fue mayor con
stent pero el IM, fue menor en este grupo con
una diferencia significativa
No hubo diferencias significativas al comprarar
stroke, muerte, IM, periprocedimiento o stroke
ipsilateral al seguimiento en ninguno de los dos
grupos.
75.
76.
77.
78.
79. Conclusiones Metanálisis BMJ.
Endarterectomía vs Angiopalstia Carotídea
End point stroke y muerte fue menor con endarterectomía,
dado por mayor stroke no discapacitante periprocedimiento
Igual incidencia de Stroke mayor .
Mayor daño de pares craneales e Infarto.
La angiopastia carotídea tuvo menor infarto y daño de
pares craneales.
80.
81. Evolución de la Evidencia Científica
Angiopalstia Primaria Vs Fibrinolíticos IAM
Task Force Indicación Clase IA.
Derivación de los Pacientes con IAM a centros con
Hemodinamia.
Task Force Indicación Clase IA.
Angioplastia Carotídea vs Endarterectomía para pacientes
de alto Riego.
Task Force Indicación Clase IA.
82. TRATAMIENTO ENDOVASCULAR
ANGIOPLASTIA CAROTÍDEA
CONSENSO ESTENOSIS CAROTIDEA
Clase I (nivel de evidencia A)
Estenosis carotídea sintomática (ECS) ≥ 50% (altamente
recomendado ≥ 70%) en pacientes con alto riesgo
quirúrgico.
Clase II (nivel de evidencia A)
ECS ≥ 50% (altamente recomendado ≥ 70%) asociada
con alguna de las siguientes condiciones:
Estenosis posradiación.
Reestenosis de una endarterectomía.
Estenosis severa en tándem.
Estenosis proximal o distal a la bifurcación.
Angioplastia carotídea con protección cerebral en
paciente asintomático con estenosis ≥ 80%, que cumpla
con lo antes mencionado.
Sociedad Argentina de Cardiología
Sociedad Neurológica Argentina
Filial de la Federación Mundial de Neurología
83. CRM vs ATC
Conarec CRM 11.7% mortalidad- vs EEUU 1%
ESMUSICA 6%
Endarterectomia vs. Angioplstia Carotídea
Endarterectomia en Argentina ????
84. En manos de Expertos
La Angioplastia carotidea es una excelente opción terapéutica
La angiografia convencional por cateter permite una evaluacion exacta del compromiso arterial. Se asocia a una morbilidad < 1% (0,1 % de episodios cerebrovasculares incapacitantes y menor al 0,1% de muerte). Una endarterectomia indicada incorrectamente resulta en el 2% de episodio cerebrovascular. Gracias a esto la angiografia se transforma en el “ gold standar” para el diagnostico de enfermedad carotidea.
La angiografia convencional por cateter permite una evaluacion exacta del compromiso arterial. Se asocia a una morbilidad < 1% (0,1 % de episodios cerebrovasculares incapacitantes y menor al 0,1% de muerte). Una endarterectomia indicada incorrectamente resulta en el 2% de episodio cerebrovascular. Gracias a esto la angiografia se transforma en el “ gold standar” para el diagnostico de enfermedad carotidea.
,
Se incluyeron pacientes con estenosis carótida común, bifuraciòn carótida y carótida interna, candidatos tanto para tto endovascular como quirúrgico Eventos mayores; stroke deshabilitante o no, muerte
The findings showed that stenting was not inferior to surgery, and the rate of the primary end point (a composite of death, stroke, or myocardial infarction within 30 days) was 39% lower among patients who were randomly assigned to protected carotid-artery stenting than among those who were assigned to undergo endarterectomy
Estudio multicentrico, ramdomizado, doble ciego, comparando la evoluciòn despuès de ATP con stent y endarterectomía.
The results show higher rates of stroke, death, or periprocedural MI in patients treated with stenting vs endarterectomy. The primary outcome of the study is the three-year rate of fatal or disabling stroke in any territory, and results are expected in 2012.
CREST is the largest prospective randomized trial to date comparing these two interventions, with 2502 patients from 117 US and Canadian centers