Behandlung extrakranieller Karotisstenosen – chirurgisch oder interventionell?

Abstract

About 200.000 people suffer form a ischemic caused stroke per year in germany. 20 % of these are caused by stenosis of the extracranial brain serving vessels, especially the internal carotid artery. Given the clinical severity of the stroke and the socio-economic outcome prevention and therapy of carotid caused strokes is highly relevant. Therapeutic or preventive options are carotid endarterectomy (CEA), carotid artery stenting (CAS) and medical treatment. Among these options the carotid endarterectomy has been proven to be significant superior against the best medical treatment. The CAS procedure is often seen as a rival to the CEA surgery.

Comparing these three options is reasonable and necessary. Therefore this article is aiming to provide a evidence based overview, considering the current data, for a differentiated indication on the therapie of relevant extracranial carotid stenosis.

Kernaussagen

• Ischämisch bedingte Schlaganfälle gehen in 20 % auf Stenosen der extrakraniellen hirnversorgenden Gefäße, insbesondere der A. carotis interna, zurück. Männer sind häufiger betroffen als Frauen, ältere Patienten häufiger als jüngere.

• Risikofaktoren einer extrakraniellen Karotisstenose sind Alter, Geschlecht und vaskuläre Faktoren wie z. B. die arterielle Hypertonie.

• Bei den extrakraniellen Karotisstenosen werden symptomatische und asymptomatische Stenosen unterschieden. Symptomatische Stenosen gehen mit einer höheren perioperativen Schlaganfallrate einher als asymptomatische Stenosen.

• Die Therapie der Karotisstenose ist als bestmögliche medikamentöse Therapie (BMT), als Karotisendarteriektomie (CEA) oder als Karotis-Stenting (CAS) möglich.

• Die Indikation zum Karotis-Stenting hängt u. a. von der klinikinternen Komplikationsrate ab. Liegt sie unter 3 %, ist die CAS bei asymptomatischen Stenosen eine Alternative zur CEA. Für die symptomatische Karotisstenose gilt eine Komplikationsrate von < 6 %. Auf Patientenseite sind das Alter, die Aortenbogenkonfiguration, die zu therapierende Seite und die Länge des/der Plaques zu berücksichtigen.

• Bei symptomatischer Karotisstenose gilt die CEA als Standardbehandlung. Leitlinienkonform kann das CAS für bestimmte Patientensubgruppen komplementär empfohlen werden. Bei asymptomatischen Karotisstenosen ist die Beurteilung schwieriger. Auch hier gilt jedoch die CEA weiter als das Standardverfahren.

• Literatur

• 1 S3-Leitlinie Extracranielle Carotisstenose; Diagnostik, Therapie und Nachsorge 2010. Gefäßchirurgie 2012; 17: 495-616
• 2 Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998; 351: 1379-1387
• 3 Mas JL, Trinquart L, Leys D et al. Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial. Lancet Neurol 2008; 7: 885-892
• 4 Grau AJ, Weimar C, Buggle F et al. Risk factors, outcome, and treatment in subtypes of ischemic stroke: the German stroke data bank. Stroke 2001; 32: 2559-2566
• 5 Inzitari D, Eliasziw M, Gates P et al. The causes and risk of stroke in patients with asymptomatic internal-carotid-artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 2000; 342: 1693-1700
• 6 de Weerd M, Greving JP, de Jong AW et al. Prevalence of asymptomatic carotid artery stenosis according to age and sex: systematic review and meta regression analysis. Stroke 2009; 40: 1105-1113
• 7 de Weerd M, Greving JP, Hedblad B et al. Prevalence of asymptomatic carotid artery stenosis in the general population: an individual participant data meta-analysis. Stroke 2010; 41: 1294-1297
• 8 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: 107-116
• 9 Berger K, Schulte H, Stogbauer F et al. Incidence and risk factors for stroke in an occupational cohort: the PROCAM Study. Prospective Cardiovascular Muenster Study. Stroke 1998; 29: 1562-1566
• 10 Ahmed B, Al-Khaffaf H. Prevalence of significant asymptomatic carotid artery disease in patients with peripheral vascular disease: a meta-analysis. Eur J Vasc Endovasc Surg 2009; 37: 262-271
• 11 Sander D, Kukla C, Klingelhofer J et al. Relationship between circadian blood pressure patterns and progression of early carotid atherosclerosis: A 3-year follow-up study. Circulation 2000; 102: 1536-1541
• 12 Pearson TA, Blair SN, Daniels SR et al. AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases. American Heart Association Science Advisory and Coordinating Committee. Circulation 2002; 106: 388-391
• 13 Ross SD, Allen IE, Connelly JE et al. Clinical outcomes in statin treatment trials: a meta-analysis. Arch Intern Med 1999; 159: 1793-1802
• 14 Heider P, Barone M, Wolf O. Schlaganfallprophylaxe aus Sicht der Gefäßchirurgen – ein Update. Gefäßchirurgie 2003; 8: 22-28
• 15 Eckstein HH, Maeder N, Allenberg JR. Carotischirurgie als Apoplexprophylaxe. Chirurg 1999; 70/4: 353-363
• 16 Halliday A, Mansfield A, Marro J et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004; 363: 1491-1502
• 17 Marquardt L, Geraghty OC, Mehta Z et al. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Stroke 2010; 41: e11-e17
• 18 Gray WA, Rosenfield KA, Jaff MR et al. Influence of site and operator characteristics on carotid artery stent outcomes: analysis of the CAPTURE 2 (Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events) clinical study. JACC Cardiovasc Interv 2011; 4: 235-246
• 19 Bonati LH, Dobson J, Algra A et al. Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned meta-analysis of individual patient data. Lancet 2010; 376: 1062-1073
• 20 Madhwal S, Rajagopal V, Bhatt DL et al. Predictors of difficult carotid stenting as determined by aortic arch angiography. J Invasive Cardiol 2008; 20: 200-204
• 21 Macdonald S, Lee R, Williams R et al. Towards safer carotid artery stenting: a scoring system for anatomic suitability. Stroke 2009; 40: 1698-1703
• 22 Naggara O, Touze E, Beyssen B et al. Anatomical and technical factors associated with stroke or death during carotid angioplasty and stenting: results from the endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis (EVA-3S) trial and systematic review. Stroke 2011; 42: 380-388
• 23 Barnett HJ, Taylor DW, Eliasziw M et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998; 339: 1415-1425
• 24 Rothwell PM, Eliasziw M, Gutnikov SA et al. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004; 363: 915-924
• 25 Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995; 273: 1421-1428
• 26 Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 2001; 357: 1729-1737
• 27 Eckstein HH, Ringleb P, Allenberg JR et al. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Lancet Neurol 2008; 7: 893-902
• 28 Ringleb PA, Allenberg J, Bruckmann H et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 2006; 368: 1239-1247
• 29 Ederle J, Dobson J, Featherstone RL et al. 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: 985-997
• 30 Brott TG, Hobson RW, Howard G et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010; 363: 11-23
• 31 Bonati LH, Jongen LM, Haller S et al. New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy of the International Carotid Stenting Study (ICSS). Lancet Neurol 2010; 9: 353-362
• 32 Yadav JS, Wholey MH, Kuntz RE et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004; 351: 1493-1501
• 33 Rothwell PM, Coull AJ, Giles M et al. Change in the stroke incidence, mortality, case-fatality, severity and risk factors in Oxfordshre, UK from 1981 to 2004 (Oxford Vascular Study). Lancet 2004; 363: 1925-1933
• 34 Asymptomatic Carotid Surgery Trial Collaborators. The MRC Asymptomatic Carotid Surgery Trial (ACST): carotid endarterectomy prevents disabling and fatal carotid territory strokes. Lancet 2004; 363: 1491-1502
• 35 Hobson RW, Weiss DG, Fields WS et al. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis: the Veterans Affairs Co-operative Study Group. N Engl J Med 1993; 345: 209-212
• 36 European Carotid Surgery Trialists Collaborative Group. Risk of stroke in the distribution of an asymptomatic carotid artery. Lancet 1995; 345: 209-212
• 37 Inzitari D, Eliasziw M, Sharpe BL et al. Risk factors and outcome of patients with carotid artery stenosis presenting with lacunar stroke; North American Symptomatic Carotid Endarterectomy Trial Group. Neurology 2000; 54: 660-666
• 38 Homepage SPACE-2-Studie, Protokollanhang zur SPACE-2-Studie „Optimale Konservative Therapie“. Version: 14.11.2008 (endgültig). www.space-2.de