Download PDF
Nervenheilkunde 2006; 25(12): 997-1002
DOI: 10.1055/s-0038-1626810
Arbeiten zum Schwerpunkt - Theme Articles
Schattauer GmbH

Die Revaskularisation der A. carotis zur Schlaganfallprophylaxe

Carotid revascularization for prevention of stroke
R. Brandl
1   Klinik für Gefäßchirurgie, Klinikum München Schwabing
,
H. Stiegler
2   Klinik für Angiologie, Klinikum München Schwabing
› Author Affiliations
Further Information

Publication History

Publication Date:
19 January 2018 (online)

    Permissions and Reprints

Zusammenfassung

Die Endarteriektomie der A. carotis ist bisher das einzige auf höchstem Evidenzniveau geprüfte invasive Verfahren zur Schlaganfallprophylaxe. Wichtigste Kriterien für die Dringlichkeit der Indikationsstellung sind patientenseitig der Stenosegrad sowie Art und Schweregrad der Symptomatik. Auf Seiten der therapeutischen Einheit steht dagegen das zentrumsspezifische periprozedurale Eingriffsrisiko. Mit Entwicklungen der Operationstechnik sowie des perioperativen Managements sind in erfahrenen Zentren sehr niedrige kombinierte Komplikationsraten zu erzielen, die mit ca. 1% für asymptomatische und2 bis 4% Morbidität und Mortalität für symptomatische Stenosen unterhalb der von den internationalen Fachgesellschaften empfohlenen Richtwerte von 3 bzw. 6% liegen. Künftige Entwicklungen in der Diagnostik zielen auf die Charakterisierung der Plaquemorphologie zur Definition besonderer Risikogruppen. Zunehmende Erfahrung und Verbesserungen der Infrastruktur lassen einen vermehrten Einsatz der CEA zur Behandlung neurologischer Ausfälle bei akuter Karotisinsuffizienz erwarten. Die Frage, welchen Stellenwert die Stentangioplastie im Vergleich zur Operation hat, wird sich demnächst aus der Metaanalyse derzeit noch laufender Studien ergeben.

Summary

Hitherto, carotid endarterectomy is the only invasive procedure for stroke prevention being evaluated by level A of evidence. The pivotal criteria for indication are degree of stenosis, type and severity of neurological symptoms as well as, on the other hand, institutional periprocedural risk. Along with developments of surgical technique and perioperative management, complication rates have been minimized in experienced centres to a level of 1% combined morbidity and mortality for asymptomatic and2 to 4% for symptomatic stenosis, thereby fulfilling the recommendations of international scientific societies of 3 and 6% respectively. Evolution of diagnostic instruments aims at morphological plaque characterization for more reliable definition of patients at risk. Growing experience and further amelioration of infrastructural conditions may contribute toa more common use of surgery for acute carotid insufficiency in emergency. The value of stent angioplasty is still being debated controversial and may evolve from meta-analyses of randomised controlled trials being completed in the near future.

Schlüsselwörter

Schlaganfall - Prävention - Karotisstenose - chirurgische Therapie - Stentangioplastie

Keywords

Stroke - prevention - carotid stenosis - surgical therapy - stent angioplasty
 

  • Literatur

  • 1 European Carotid Surgery Trialists Collaborative Group. MRC European Carotid Surgery Trial: Interim results for symptomatic patients with severe (70–99%) or mild carotid stenosis (0–29%). Lancet 1991; 337: 1235-43.
    CrossrefPubMedGoogle Scholar
  • 2 North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high grade stenosis. N Engl J Med 1991; 325: 445-53.
    CrossrefPubMedGoogle Scholar
  • 3 Asymptomatic carotid atherosclerosis study group. Carotid endarterectomy for patients with asymptomatic internal carotid artery stenosis. JAMA 1995; 273: 1421-8.
    CrossrefPubMedGoogle Scholar
  • 4 MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004; 363: 1491-502.
    CrossrefPubMedGoogle Scholar
  • 5 Jacobowitz GR, Rockman CB, Gagne PJ, Adelman MA, Lamparello PJ, Landis R, Riles TS. A model for predicting occult carotid artery stenosis: Screening is justified in a selected population. J Vasc Surg 2003; 38: 705-9.
    CrossrefPubMedGoogle Scholar
  • 6 Nicolaides AN, Kakkos SK, Griffin M, Dhanjil S, tegos T, Thomas DJ, Giannoukas A, Geroulakos G, Georgiou N, Francis S, Ioannidou E, Doré CJ. For the Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group. Eur J Vasc Endovasc Surg 2005; 30: 275-84.
    CrossrefPubMedGoogle Scholar
  • 7 Naylor AR, Rothwell PM, Bell PRF. Overview of the Principal Results and Secondary Analyses from the European and North American Randomised Trials of Endarterectomy for Symptomatic Carotid Stenosis. Eur J Vasc Endovasc Surg 2003; 26: 115-29.
    CrossrefPubMedGoogle Scholar
  • 8 Alamowitch S, Eliasziw M, Barnett HJ. The risk and benefit of endarterectomy in women with symptomatic internal carotid artery disease. Stroke 2005; 36: 27-31.
    CrossrefPubMedGoogle Scholar
  • 9 Brandl R, Richter Th, Haug K, Wilhelm MG, Maurer PC, Nathrath W. Topographic analysis of proliferative activity in carotid endarterectomy specimens by immunocytochemical detection of the cell cycle related antigen Ki-67. Circulation 1997; 96: 3360-8.
    CrossrefPubMedGoogle Scholar
  • 10 Eckstein HH, Umscheid T, Noppeney T, Weber H, Niedermeier HP. Qualitätsmanagement “Karotis” der Deutschen Gesellschaft für Gefäßchirurgie – Ergebnisse 1999. Kommission Qualitätssicherung der Deutschen Gesellschaft für Gefäßchirurgie (DGG). Gefäßchirurgie 2001; 06: 81-90.
    CrossrefGoogle Scholar
  • 11 Cao P, Giordano G, De Rango P. et al. and Collaborators of the Everest Study Group. Eversion versus conventional carotid endarterectomy: late results of a prospective multicenter randomized trial. J Vasc Surg 2000; 31: 19-30.
    CrossrefPubMedGoogle Scholar
  • 12 Naylor R, Hayes PD, Payne DA, Allroggen H, Steel S, Thompson MM, London NJ, Bell PR. Randomized trial of vein versus dacron patching during carotid endarterectomy: Long-term results. J Vasc Surg 2004; 39: 985-93.
    CrossrefPubMedGoogle Scholar
  • 13 Brandl R, Brauer R, Maurer PC. Urgent carotid endarterectomy for stroke in evolution. VASA 2001; 30: 115-21.
    CrossrefPubMedGoogle Scholar
  • 14 Anonym. 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: 1729-37.
    CrossrefPubMedGoogle Scholar
  • 15 Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK, Whitlow P, Strickman NE, Jaff MR, Popma JJ, Snead DB, Cutlip DE, Firth BG, Ouriel K. Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy Investigators. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004; 351: 1493-501.
    CrossrefPubMedGoogle Scholar
  • 16 Alamowitch S, Eliasziw M, Algra A, Meldrum H, Barnett HJM. for the NASCET Trial. Risk, causes and prevention of ischaemic stroke in elderly patients with symptomatic internal carotid artery stenosis. Lancet 2001; 357: 1154-60.
    CrossrefPubMedGoogle Scholar
  • 17 Hacke W. Persönliche Kommunikation, Brüssel, Mai. 2006
    PubMedGoogle Scholar
  • 18 Branchereau A. Persönliche Kommunikation. Brüssel: Mai 2006
    PubMedGoogle Scholar