Karotid Mikroendarterektomi Endikasyon ve Cerrahi Teknik

KAROTİD MİKROENDARTEREKTOMİ
ENDİKASYON VE CERRAHİ TEKNİK

Turk Norosirurji Dernegi
26. Bilimsel Kongresi
Belek Antalya 20-24 Nisan 2012

Prof. Dr. Nihat EGEMEN,
Ankara Universitesi Tıp Fak.
Beyin ve Sinir Cerrahisi A.B.D.


EKSTRAKRANİAL KAROTİS HASTALIKLARI

1- KAROTİS STENOZU
a- İKA
b- ECA

2- KAROTİS TAM TIKANIKLIĞI
a- KKA
b- İKA
c- EKA

EGEMEN


İNTERNAL KAROTİD ARTER STENOZU

1. GEÇİCİ İSKEMİK ATAKLAR (GİA)
• Hemisferik Ataklar
• Geçici Körlükler (Amorozis Fugaks)
• 7-10 dk. sürer 24 satten kısa.
2. GERİ DÖNEN İSKEMİK NÖROLOJİK DEFİSİT (GİND)
• 24 saat’ten fazla 3 haftadan az.
3. İNME
• Serebral infakt sonucu değişik şiddette kalıcı nörolojik
defisitler.
EGEMEN


YOĞUN STENOZUN OLDUĞU VE GİA GEÇİREN
HASTALARDA SEMPTOMLARIN ORTAYA ÇIKMASINI
TAKİB EDEN 1. YILDAKİ İNME RİSKİ
% 12- 13
BEŞ YIL SONUNDAKİ TOPLAM İNME RİSKİ
% 30-35

EGEMEN


NASCET
North American Symptomatic Carotid Endarterectomy Trial
Completed
1991
Status
Trial complete. Initial results published 8/91.

Trial Phase
Phase III

Sponsor
National Institute of Neurologic Disorders and Stroke, NIH

Results
The risk of ipsilateral stroke was reduced significiantly (p=0.045)
in patients with carotid stenosis 50-69% who received carotid
endarterectomy. Patients with stenosis of 70-99% showed the
most significant reduction(p < 0.001) in the rate of ipsilateral
stroke while patients with stenosis of <50% did not show a
significantly lower rate of ipsilateral stroke.
EGEMEN


EKSTRAKRANİAL KAROTİS HASTALIKLARI

Arterioskleroz
ilerleyicidir

EGEMEN


EGEMEN


Serebral İskemi
Semptomatik Hasta

MRI+ Medikal ve Kardiak tetkik + aspirin

Semptom devam ediyor Semptom devam ediyor
Tıbbi ve Kardiak Neden var non Kardiak- Non medikal hasta

Uygun tedavi Angiografi

VertebroBaziler IKA oklüzyonu karotis Bif. Darlığı IKA oklüzyonu Normal

Güdük + EKA hast. Güdüksüz Çok Az Hasta
Aspirin/Coumadin
Karotis Mikro-
Stumpektomi+ EKA Endarterektomi
Semptomatik Aspirin+Takip
endarterektomi
MRI,Xenon BT,
SKA çalışmaları Aspirin/ Coumadin
Ekstrakranial/ İntrakranial
Rekonstrüksiyon/Revaskülerizasyon
Semptomlar Devam ederse
EGEMEN


Aspirin/ Coumadin

Semptomlar Devam ederse

SPECT/MRI/ Xenon BT, SKA çalışması

Hipoperfüzyon/ İskemi var Hipoperfüzyon/ İskemi yok

Medikal Tedavi ve takip
Revaskülerizasyon-
STA- MCA ANASTAMOZ-
VEN GREFTİ İLE ANASTOMOZ
EGEMEN


AMERİKA BİRLEŞİK DEVLETLERİNDE
İLK KAROTİD ENDARTEREKTOMİ 1950 YILINDA YAPILDI
1971 YILINDA 17000 KİŞİYE
1999 YILINDA 130.000 KİŞİYE KAROTİS ENDARTEREKTOMİ
YAPILMIŞTIR.
TÜRKİYEDE YILDA *!!!!!!!!* ENDARETEREKTOMİ ?????

NEDEN AZ ?
TÜRKİYEDE SENEDE 90-100 BİN YENİ İSKEMİK HASTA
GÖRÜLMEKTEDİR

EGEMEN


KLİNİĞİMİZDE VE TÜRKİYEDE
KAROTİD MİKROENDARTEREKTOMİ İLK KEZ
PROF. DR. NURHAN AVMAN
TARAFINDAN 1974 YILINDA YAPILMIŞTIR!
(1974- 2012)

EGEMEN


AMELİYAT ÖNCESİ TANI
KLİNİK BELİRTİ

NÖROLOJİK MUAYENE
*RENKLİ KAROTİD DOPLER
*CT
*MRI

MRA/** BTA/** DSA
- BOYUN SEGMENTİ,
- İNTRAKRANİAL ARTERİAL YAPI,
- ARKUS ÇIKIŞLARI

EGEMEN


RENKLİ KAROTİD DOPLER

EGEMEN


MRI BT

EGEMEN


MRA DSA

EGEMEN


BT ANGİOGRAFİ PREOP

EGEMEN


BT ANGİOGRAFİ POST OP

EGEMEN


STENOZ

ANGİOPLASTİ
SONRASI

EGEMEN


DSA- VE DARLIK YÜZDESİ

EGEMEN


 Xenon CT
( Asetolozamid)
 SPECT
 MRI- perfüzyon
 MRI- difüzyon
 Serebral kan akımı

EGEMEN


MRI- T2 flair MRI- difüzyon ADC
haritası

EGEMEN


AMELİYAT ÖNCESİ

1. HİPERTANSİYON
2. İSKEMİK VE KONJESTİF KALP HASTALIKLAR
3. DİABETES MELLİTUS

4. PULMONER HASTALIKLAR

YÖNÜNDEN DEĞERLENDİRİLİRLER

EGEMEN


AMELİYAT ÖNCESİ VE SONRASI DÖNEMDE
MEDİKAL TEDAVİ
ASPİRİN 300 MG/GÜN

ASPİRİN VEREMEDİĞİMİZ HASTALARDA PLAVİX 75 mg
KULLANMAKTAYIZ

EGEMEN


ENDİKASYONLAR

1-SEMPTOMATİK HASTALAR
İKA de % 70 ve üzeri darlık
İKA de C tip Ülser
ve medikal tedaviye rağmen
GİA geçiren B tipi ülserler.

2- ASEMPTOMATİK HASTALAR
İKA de % 60 üzeri darlık
EGEMEN


MİKROSKOP YARDIMI İLE YAPILAN ENDARTEREKTOMİ

“KAROTİD MİKROENDARTEREKTOMİ”
MÜKEMMEL AYDINLATMA, MİKROSKOP ÇEŞİTLİ BÜYÜTMELERDE
GÖRÜNTÜ VE ÇEŞİTLİ AÇILARDAN BAKIŞ SAĞLAR.

MİKROSKOP KAROTİD CERRAHİSİNİN VE
MİKROCERRAHİ TEKNİĞİNİN ÖĞRENİLMESİNEDE YARDIMCIDIR

EGEMEN


KAROTİD ARTER TAMİRİNİ KOLAYLAŞTIRIR VE İYİLEŞTİRİR

DİSTAL KAROTİD ARTERİN DAHA İYİ GÖRÜNTÜLENMESİNİ,

ARTERİOTOMİNİN YAMA KULLANILMADAN
KAPATILMASINI
VE
İYİ DÖKÜMENTASYON SAĞLAR.

AMELİYAT SÜRESİNİ KISALTIR. ( 17 dak.)

EGEMEN


1. GENEL ANESTEZİ
2. BEYNİ İSKEMİDEN KORUMAK AMACI İLE
250 mg. SODİUM THİOPENTAL (İV) .
3. TROMBÜS OLUŞUM RİSKİNİ AZATMAK AMACI İLE
5000 İÜ. HEPARİN (İV) VERİLİR.
4. KAN BASINCI TAKİBİ YAPILARAK HİPOTANSİYONDAN
KAÇINILIR.
5. EĞER KARŞI KAROTİS ARTER TAM TIKALI DEĞİL İSE
ŞANT KULLANILMAZ.
6. KAROTİD ARTER 6.0 PROLEN İLE YAMA
KULLANILMAKSIZIN KAPATILIR.

EGEMEN


MİKRODOPLER

EGEMEN


ATEROM PLAĞI

EGEMEN


Aterom plaklarının iç yüzündeki ülserasyonlar

EGEMEN

PREOP KAROTİD MİKROENDARTEREKTOMİ
POST OP

EGEMEN


Primary closure after a carotid endarterectomy. Surg Today.
2007;37(3):187-91. Epub 2007 Mar 9.
Kim DI, Moon JY Lee CH, Kim DY Jang YS, Kim GM, Chung CS Lee
KH, Kim SW
Division of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of
Medicine, 50 Irwondong, Kangnamku, Seoul, 135-710, South Korea.
PURPOSE: The prevalences of restenosis and stroke after a carotid
endarterectomy (CEA) tend to differ substantially according to the surgeon.
Primary closure after a CEA was the routine procedure in our institute. The
primary objectives of this study were to compare the results of patients of a
primary arteriotomy closure in CEA between our own and others' results based
on the findings in the literature. METHODS: One hundred and sixty-six patients
who underwent a primary closure were analyzed. Perioperative neurologic
deficits were determined by the neurologist. Restenosis was defined as >50%
stenosis on duplex scan. The range of follow-up was 7-112 months. RESULTS:
Stroke including transient ischemic attack occurred within 30 postoperative
days in 3 patients and after 30 postoperative days in 1 of the 166 patients. Five
patients showed >50% asymptomatic restenosis. Two patients were treated
with stent insertion and one underwent reoperation. One patient showed total
occlusion during the follow-up period without any neurological deficits. One
patient showed 50%-70% stenosis, and no intervention was done.
CONCLUSIONS: The rates of recurrent stenosis and postoperative
stroke were found to be sufficiently low following a primary closure
to justify the continued use of this technique

EGEMEN


Plavix+ asprin kullanan
hastada cilt altına sızıntı
tarzında hematom

EGEMEN


MRI da İskemik bölge

EGEMEN


DSA da trombüs

EGEMEN


EKA STENOZU PREOP

EGEMEN


EKA STENOZU POST OP

Post op ICA da rekanalizasyon
EGEMEN


Perspect Vasc Surg Endovasc Ther. 2006 Dec;18(4):300-3; discussion 304-5.
Links
Carotid stent trials: past, present, and future.
Quirel K
Division of Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA. ourielk@ccf.org
Carotid stenting has emerged as a therapeutic alternative to standard
carotid endarterectomy in patients with carotid bifurcation disease. The
percutaneous modality holds the potential to replace a large proportion of
the carotid surgical procedures performed throughout the world.
Carotid stenting has undergone technologic advances in the last decade,
including improved sheaths and guides, lower profile balloons and stents,
and the almost ubiquitous use of dependable distal embolization protection
devices.
Contemporary data confirm the safety and efficacy of the procedure for
patients with high-grade lesions who are at higher-than-normal risk for
standard open carotid repair.

Whether lower-risk patients should be offered stenting as an alternative to
carotid endarterectomy is a question that must await the results of ongoing
clinical trials

EGEMEN

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