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1、2008,Intervention for Asymptomatic Carotid Stenosis should be Stratified,罗建方 广东省人民医院 Jianfang Luo, M.D. Guangdong Cardiovascular Institute Guangdong Provincial Peoples Hospital,2008,The mechanism of stroke with carotid lesion,Emboli,Hypoperfusion,Clinical symptoms caused by embolic disease in 80% of
2、 patients 20% by hemodynamic impairment,2008,Posterior Inferior Cerebellar Artery,Internal Carotid Artery,Vertebral Artery,Athrosclerotic plaque,Thrombus,Embolus,Occlusive thrombus,Cerebral Circulation and Thromboembolic Lesions,Why should treat carotid lesion？,2008,Carotid Stenosis,2008,Symptomatic
3、 Carotid Stenosis Natural History,Carotid stenosis + TIA Risk of stroke in 1st yr = 12-13% 5th yr = 30-37% Sundt et al., 1987 Dennis et al. Stroke, 1990,2008,Asymptomatic Carotid Stenosis Natural History,Stenoses 75% risk of stroke in 1st yr = 2-5% Roederer et al. Stroke, 1984 Hennereci et al. Brain
4、, 1987,2008,Major stroke by stenosis severity,2008,Risk of stroke in patients with asymptomatic carotid stenosis has fallen significantly.,Abbott et al., International Journal of Stroke, 2007.,2008,ATROCAP： Atorvastatin 20mg Stabilize plaque,“Stabilizing plaque is an important mechanism to reduce ca
5、rdiovascular and cerebral events.”,Mean Percent change （%),-60,-50,-40,-30,-20,-10,0,Ulceration,Inflammation,Macrophage,Placebo（n=30）,Lipitor20mg（n=29）,Cortellaro M et al. Thromb Haemost. 2002;88:41-47.,2008,Risk Stratification of Asymptomatic Carotid Stenosis,Eur J Vasc Endovasc Surg xx, 1e10 (2008
6、),2008,Plaque morphology：“High Risk”,2008,“Vulnerable” plaque in carotid specimen,2008,Lesion morphologies in carotid artery,2008,Plaque Morphology and Stroke Risk,Ulceration = Iminent stroke risk of stroke = 7.5% Autret et al. Lancet, 1987 Heterogeneous and ulcerated lesions = Risk 2-4 x Langsfeld
7、et al. J Vasc Surg, 1989 Sterpetti et al. Stroke, 1988,2008,What we know now,The risk of stroke is relevant to severity of stenosis Histological data from the coronary and carotid circulations suggest that other plaque features may be more important in predicting future thrombo-embolic events.,2008,
8、Revascularization for Asymptomatic Carotid Stenosis,Stratification Strategy,2008,颈动脉狭窄的治疗方法,1药物治疗 （Medical Therapy） 2颈动脉内膜剥离术 （Carotid Endarterectomy, CEA） 3经皮颈动脉支架植入术 （Carotid Artery Stenting, CAS）,2008,The Cochrane Collaboration 2006 ASA 2006,2008,Step 1 ：High Risk of Stroke,Severe Carotid Stenosi
9、s （80%） + Unfavorable Plaque Features （ulceration or heterogenecity ）,2008,Step 2 ：High Risk for Stenting,High risk Patients 80 y of age (asymptomatic) Access problems Baseline large neurological defect Marked cerebral atrophy + microangiopathy Dementia / Alzheimer High risk Anatomy Obvious filling
10、defect / thrombus Vessel occlusion “String” sign - asymptomatic Severe distal loops/kinks/bends Heavy concentric calcifications Type III aorta arch,2008,High risk for intervention,2008,Any 2 of the following = High Risk,AGE 80,Cerebral Reserve,Excessive Tortuosity,Heavy concentric calcification,Criteria of High Risk Carotid Stenting,2008,Proposed New Paradigm,Need good training Dont forget optimal medical therapy !,2008,Thank you !,