Asemptomatik hastalarda karotis arter stentleme ve karotis endarterektominin prosedürel ve orta dönem sonuçları: Tek merkez deneyimi

Year 2020, , 168 - 185, 22.06.2020

Ali Baran Budak Husniye Sarıyıldız Eren Gunertem Emre Kulahcıoglu Gurdal Orhan Naim Boran Tumer Atike Tekeli Kunt Kanat Özışık Serdar Günaydın

https://doi.org/10.18663/tjcl.739395

Abstract

Amaç: Aterosklerotik Karotid Arter Stenozu (CS) tüm inmelerin %20’sinden sorumludur. Asemptomatik CS yönetimi daha belirsizdir. Hastaya özel tedavi için, Karotis Endarterektomi (KEA) işleminin daha riskli olduğu durumlarda, cerrahlar ayrıca karotis arter stentlemesi (KAS) yapabilecek tecrübe ve kapasitede olmalıdır. Bu çalışmada, tüm işlemleri (KAS ve KEA) aynı cerrah yapmış ve tek tip stent ve emboli koruma aracı kullanılmıştır. Ayrıca, prosedür sırasındaki monitorizasyon 24 saate yayılmıştır. Bu çalışmanın amacı, aynı operatör tarafından 1 yılda KAS veya KEA uygulanan asemptomatik CS hastalarının işlem ve takip sonuçlarını karşılaştırmaktır.
Gereç ve Yöntemler: İnternal karotid arter ciddi oklüzyonu nedeniyle klinik ve anatomik risk profillerine göre, 1.Ocak.2018-31.Aralık 2018 tarihleri arasında Ankara Numune Eğitim ve Araştırma Hastanesi Kalp-Damar Cerrahi Kliniğinde KAS (Grup 1, n=17) veya KEA (Grup 2, n=18) uygulanan asemptomatik hastaların retrospektif incelemesi yapıldı. Doppler Ultrason ve nörolojik değerlendirme hastalar işleme alınmadan, taburcu olmadan, prosedür sonrası 30.gün, 6.ay ve 1.yılda yapıldı. Hastaların demografik ve klinik özellikleri, anjiyografik değişkenleri, işlem sonrası 30 gün boyunca ölüm, inme ve miyokard enfarktüsü ve 1 yıllık ipsilateral inme oranları karşılaştırıldı. Teknik başarı, prosedür başarısı, birincil açıklık , klinik başarısızlık, işlem sırasında yardımcı manevraları içeren diğer birincil sonlanım noktaları ve komplikasyonlar, 12 ayda klinik olarak yönlendirilen hedef lezyon revaskülarizasyonundan kurtulma, ölümden kurtulma, tüm felçlerden kurtulma ve restenoz oranlarından kurtulma oranlarını içeren ikincil sonlanım noktaları değerlendirildi ve gruplar arasında karşılaştırıldı.
Bulgular: Sekiz hastada (47.0%) yüksek riskli anatomik kriter ve 11 hastada (%64.7) yüksek riskli klinik kriterler mevcuttu. Grup 2’deki hastalar daha yaşlı (67.7±7.4 vs 71.2± 6.9, p<0.05) idi, ancak hiperlipidemi (58.8% vs 44.4%, p<0.05), hemodiyaliz gerektiren kronik böbrek yetmezliği (11.7% vs 0.0%, p<0.05) ve sol ventrikül disfonksiyonu (17.6% vs 0.0%, p<0.05) sıklığı Grup 1’de fazlaydı. Grup 1’deki hastaların CCDS skoru Grup 2’ye göre düşüktü (4.7 ± 1.3 vs 7.3 ± 1.2; p<0.05). CEA yapılan hastaların lezyonları daha uzun (12.7 ± 2.6 vs 18.5 ± 4.2 mm.; p<0.05) ve daha kalsifikti (11.7% vs 50.0%, p<0.05). Benzer şekilde, grup 2’de damardaki darlık derecesi grup 1’e göre yüksek bulundu (81.4 ± 4.2 vs 88.3±6.4 %; p<0.05). Primer teknik başarı her iki grup için de %100 idi. Prosedürel klinik başarı Grup 1 için %100, Grup 2 için %94.4 idi. Primer patens oranları grup 1 için 1/6/12. aylarda 100%/ 94.1%/94.1%, grup 2 için 100%/100%/94.4%. restenozdan ve klinik olarak yönlendirilen hedef lezyon revaskülarizasyondan kurtulma oranları grup 1 için %94.1, grup 2 için %94.4 idi. Hiçbir hastada ölüm, major inme, miyokard infarktüsü ve sistemik komplikasyon gerçekleşmedi.
Sonuç: Bu çalışma, önemli karotis hastalığı olan asemptomatik hastalarda KEA ve KAS için benzer kısa ve orta dönem sonuçları göstermiştir. Hem KEA hem de KAS için iyi sonuçlar göstersek de, KAS açık cerrahi için uygun olmayan vakalarla sınırlı olmalı ve az risk faktörü ve uzun yaşam beklentisi olan hastalar için asemptomatik karotid arter hastalığının KEA ile tedavisi düşünülmelidir. Hem KEA hem de KAS asemptomatik hastalarda uzun süreli inme riskini azaltır. Uygun tedavi stratejisi, hastanın bireysel risk faktörlerine ve görüntüleme verilerine göre seçilmelidir.

Keywords

asemptomatik, karotis arter stentleme, karotis endarterektomi

Procedural and mid-term outcomes of carotid artery stenting and carotid endarterectomy in asymptomatıc patients: A single center experience

Abstract

Aim: Atherosclerotic carotid artery stenosis (CS) is responsible for ~20% of strokes. The management of CS in an asymptomatic patient has been less clear. In situations were carotid endarterectomy (CEA) is thought to be more risky, surgeons must also have enough experience and capability to perform carotid artery stenting (CAS) to provide suitable, patient-tailored treatment. In this study, the same investigator performed all interventions (CAS and CEA), and one type of stenting device and EPD was used. In addition, periprocedural monitoring was carried out for at least 24 h. The objective of this study was to compare procedural results and 12-month follow-up outcomes of patients who were treated by the same operator- either CAS or CEA- in one year.
Material and Methods: A retrospective single-center review involving asymptomatic patients with severe stenosis of the ICA caused by atherosclerotic disease who was treated with either stenting with embolic protection (Group 1, n=17) or carotid endarterectomy (group 2, n=18) according to their clinical and anatomical risk profile between 1 January 2018 and 31 December 2018 at Numune Research and Training Hospital, Department of Cardiovascular Surgery, Ankara-Turkey was conducted. A duplex ultrasound (DUS) and neurological assessment was obtained prior to hospital discharge as a baseline, 30-days, 6 months, and 1 year thereafter. Patients’ demographic and clinical characteristics, angiographic variables, primary endpoints including the composite of death, stroke and myocardial infarction during the 30 days after the procedure or ipsilateral stroke during the 365 days after the procedure was compared. Primary endpoints also including primary technical success, periprocedural clinical success, primary patency, clinical failure, periprocedural adjunctive maneuvers and secondary endpoints including complications, freedom from clinically driven target-lesion revascularization at 12 months, freedom from death, freedom from all stroke and freedom from restenosis rates were assessed and compared between the groups.
Results: High-risk anatomical criteria were present in 8 (47.0%) patients, high-risk clinical criteria were present in 11 (64.7%) patients. Group 2 patients were older (67.7±7.4 vs 71.2± 6.9, p<0.05), but hyperlipidemia (58.8% vs 44.4%, p<0.05), chronic renal insufficiency requiring hemodialysis (11.7% vs 0.0%, p<0.05) and left ventricular dysfuntion (17.6% vs 0.0%, p<0.05) were significantly more frequent in Group 1. CCDS of group 1 was significantly lower than group 2 (4.7 ± 1.3 vs 7.3 ± 1.2; p<0.05, respectively). The lesions of the patients undergoing CEA were significantly longer (12.7 ± 2.6 vs 18.5 ± 4.2 mm.; p<0.05) and more calcified (11.7% vs 50.0%, p<0.05) than the patients in group 1. Likewise, the degree of stenosis in group 2 was significantly more than that of group 1 (81.4 ± 4.2 vs 88.3±6.4 %; p<0.05, respectively). Primary technical success was 100% for both groups. Periprocedural clinical success was 100% for Group 1, and 94.4% for group 2. Primary patency rates at 1/6/12 months were 100%/ 94.1%/94.1% for group 1, and 100%/100%/94.4% for group 2. Freedom from restenosis and freedom from CD-TLR at 12 months was 94.1% and 94.4% for group 1 and group 2. No death, major strokes, miyocardial infarction and systemic complications occured.
Conclusion: This study showed similar short and mid-term results for CEA and CAS in asymptomatic patients with significant carotid disease. Although we have shown good results for both CEA and CAS, CAS should be limited to those cases that are not suitable for open surgery and treatment of asymptomatic carotid artery disease with CEA should be considered for patients with few risk factors and long life expectancy. Both CEA and CAS reduce the long-term stroke risk in asymptomatic patients. The appropiate treatment strategy should be selected according to the patient’s individual risk factors and imaging data.

Keywords

asymptomatic, carotid artery stenting, carotid endarterectomy

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