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1、GDPPH, JF LuoIntervention for Asymptomatic Carotid Stenosis should be Stratified 罗建方罗建方 广东省人民医院广东省人民医院Jianfang Luo, M.D.Guangdong Cardiovascular InstituteGuangdong Provincial Peoples Hospital2008GDPPH, JF LuoThe mechanism of stroke with carotid lesion Emboli Hypoperfusion n n Clinical symptoms cause
2、d by embolic disease in 80% of patientsn 75%risk of stroke in 1st yr = 2-5% Roederer et al. Stroke, 1984 Hennereci et al. Brain, 19872008GDPPH, JF LuoMajor stroke by stenosis severity2008GDPPH, JF LuoRisk of stroke in patients with asymptomatic carotid stenosis has fallen significantly.Abbott et al.
3、, International Journal of Stroke, 2007.2008GDPPH, JF LuoATROCAP： Atorvastatin 20mg Stabilize plaque“Stabilizing plaque is an important mechanism to reduce cardiovascular and cerebral events.”Mean Percent change （%)-60-50-40-30-20-100UlcerationInflammationMacrophagePlacebo（n=30）Lipitor20mg（n=29）Cort
4、ellaro M et al. Thromb Haemost. 2002;88:41-47.2008GDPPH, JF LuoRisk Stratification of Asymptomatic Carotid StenosisEur J Vasc Endovasc Surg xx, 1e10 (2008)2008GDPPH, JF LuoPlaque morphology：“High Risk” 2008GDPPH, JF Luo“Vulnerable” plaque in carotid specimen2008GDPPH, JF LuoLesion morphologies in ca
5、rotid artery2008GDPPH, JF LuoPlaque Morphology and Stroke RiskUlceration = Iminent stroke risk of stroke = 7.5% Autret et al. Lancet, 1987Heterogeneous and ulcerated lesions = Risk 2-4 x Langsfeld et al. J Vasc Surg, 1989 Sterpetti et al. Stroke, 1988 2008GDPPH, JF LuoWhat we know nowThe risk of str
6、oke is relevant to severity of stenosisHistological data from the coronary and carotid circulations suggest that other plaque features may be more important in predicting future thrombo-embolic events. 2008GDPPH, JF LuoRevascularization for Asymptomatic Carotid StenosisStratification Strategy2008GDP
7、PH, JF Luo 颈动脉狭窄的治疗方法颈动脉狭窄的治疗方法 1药物治疗药物治疗 （Medical Therapy）2颈动脉内膜剥离术颈动脉内膜剥离术 （Carotid Endarterectomy, CEA）3经皮颈动脉支架植入术经皮颈动脉支架植入术 （Carotid Artery Stenting, CAS） 2008GDPPH, JF LuoThe Cochrane Collaboration 2006 ASA 20062008GDPPH, JF LuoStep 1 ：High Risk of StrokeSevere Carotid Stenosis （80%） +Unfavorab
8、le Plaque Features （ulceration or heterogenecity ）2008GDPPH, JF LuoStep 2 ：High Risk for StentingHigh risk Patients 80 y of age (asymptomatic)Access problemsBaseline large neurological defectMarked cerebral atrophy + microangiopathyDementia / Alzheimer High risk AnatomyObvious filling defect / throm
9、busVessel occlusion“String” sign - asymptomatic Severe distal loops/kinks/bends Heavy concentric calcificationsType III aorta arch2008GDPPH, JF LuoHigh risk for intervention2008GDPPH, JF LuoAny 2 of the following = High RiskAGE 80Cerebral ReserveExcessive TortuosityHeavy concentric calcificationCriteria of High Risk Carotid Stenting2008GDPPH, JF LuoProposed New ParadigmCarotid Revascularization Indicated?YesNoHigh Stent RiskYesNoMedical ManagementSurveillanceCEA if low riskCarotid StentNeed good trainingDont forget optimal medical therapy !2008GDPPH, JF LuoThank you !2008
