Πόσο σίγουροι είμαστε για το όφελος της ενδαρτηρεκτομής

στην ασυμπτωματική καρωτιδική στένωση;

Γ ε ώ ρ γ ι ο ς Ν τ ά ι ο ς

Π α θ ο λ ο γ ι κ ή Κ λ ι ν ι κ ή & Ο μ ώ ν υ μ ο Ε ρ ε υ ν η τ ι κ ό Ε ρ γ α σ τ ή ρ ι ο

Ι α τ ρ ι κ ή Σ χ ο λ ή Π α ν ε π ι σ τ η μ ί ο υ Θ ε σ σ α λ ί α ς

Αθήνα30/11/2013

Disclosures• Support to attend educational activities: Bayer; Sanofi-Aventis; Pfizer;

Lundbeck; Boehringer-Ingelheim; Galenica; Elpen; Bristol Myers Squibb.

• Honoraria: Quintiles; Medtronic.

• Speaker fees: Sanofi

• Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis.

• Participation in trials– National coordinator (Greece) for the ENOS trial.– Sub-investigator (AMGEN, 20110118).

JAMA 1995; 273:1421-1428

ACAS: Asymptomatic Carotid Artery Study

JAMA 1995; 273:1421-1428

5.1%

11%

Lancet 2004; 363: 1491–502

ACST: Asymptomatic Carotid Surgery Trial

Lancet 2004; 363: 1491–502

ACST: Asymptomatic Carotid Surgery Trial

Lancet 2004; 363: 1491–502

Stroke 2011; 42(8):e464-540

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

ACST: Asymptomatic Carotid Surgery Trial

Lancet 2004; 363: 1491–502

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

Best (???) medical treatment

Lancet 1996; 348: 1329–39

CAPRIE: Clopidogrel vs. Aspirin

Lancet 1996; 348: 1329–39

Best (???) medical treatment

- Better antiplatelets are available now

ACST: Asymptomatic Carotid Surgery Trial

Lancet 2004; 363: 1491–502

ACST: Asymptomatic Carotid Surgery Trial

Lancet 2004; 363: 1491–502

Stroke 2008; 39: 3297–3302

Stroke 2008; 39: 3297–3302

Best (???) medical treatment

- Better antiplatelets are available now

- 30% did not receive statin

Excellent safety record

an annual minimum of 12 carotid endarterectomies

mortality/morbidity rate <3% in the last 50 cases.

40% of initial applicants were rejected

2 strokes/deaths temporarily suspended

ACAS: Asymptomatic Carotid Artery Study

Stroke 2009; 40:e573– e583

International Journal of Stroke 2009; 4:294-299

International Journal of Stroke 2013, e-pub ahead of print

Degree of stenosis

Stroke 2000; 31:615-621

Stroke 2000; 31:615-621

Plaque surface

Stroke 2011; 42:972-978

Total plaque area

Stroke 2006; 37:818-823

Radiology 2009; 252: 502-8

Intraplaque hemorrhage

Radiology 2009; 252: 502-8

Lancet Neurol 2010; 9: 663–71

Microembolic signals

Lancet Neurol 2010; 9: 663–71

Microembolic signals

Lancet Neurol 2010; 9: 663–71

Silent strokes

J Vasc Surg 2009;49:902-9

Silent strokes

J Vasc Surg 2009;49:902-9

- D e g r e e o f s t e n o s i s- P l a q u e s u r fa c e- To t a l p l a q u e a r e a- F i b r o u s c a p- I n t ra p l a q u e h e m o r r h a g e- M i c r o e m b o l i- S i l e nt s t r o ke s

Take home messages