Postępowanie w niedrożności tetnic szyjnych
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Niedrożność i krytyczne zwężenie tętnic szyjnych stanowią poważny problem terapeutyczno-leczniczy. Prezentujemy zasady postępowania i prezentujemy 2 przypadki leczenia krytycznych zwężeń tętnic szyjnych
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Postępowanie w niedrożności tetnic szyjnych
- 1. Management of patients with internal carotid artery occlusion and near-total occlusion Michał Molski1 , Jan Szczepański1 , Wacław Kuczmik2 , Stanisław Molski1 1 Oddział Chirurgii Naczyniowej, Ogólnej I Angiologii, Szpital Eskulap – Centrum Leczenia Chorób Serca i Naczyń 2 Katedra i Klinika Chirurgii Ogólnej i Naczyniowej Śląskiego Uniwersytetu Medycznego
- 2. Total Carotid Occlusion (TCO) • Symptomatic TCO incidence rate 6/100 000 – Stroke, TIA, amaurosis fugax • Asymtomatic – syncopal episodes – Retinal caudication – progressive loss of visual acuity – Limb shaking – Unaccustomed headaches – ipsilateral brisk pulsations at the angle of the jaw, brow and cheek, the so-called ABC pulsations of Fisher
- 3. TCO revascularisation • Acute – BMT – Thrombolysis – Thrombendarterectomy • Chronic – BMT – external carotid–internal carotid bypass surgery – Endarterectomy – Angioplasty and stenting The EC/IC Bypass Study Group. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke: results of an international randomized trial. N Engl J Med. 1985;313:1191-1200. Wade JPH, Wong W, Barnett HJM, Vandervoort P. Bilateral occlusion of the internal carotid arteries. Brain. 1987;110:667-682.
- 4. Near-total Carotid Occlusion (NTCO) • is defined as a severe stenosis of the internal carotid artery with a narrow residual lumen and a collapsed distal portion induced by hypoperfusion • >95% • Ratio of diameters of CCA / ICA >4
- 5. Diagnostic problems of TCO / NTCO • It is very often difficult to distinguish total occlusion from near total occlusion – Doppler US in 85% confirmes patency NTCO • Power doppler superior to color doppler • Contrast enhanced US
- 6. Diagnostic problems of NTCO angio-CT
- 7. Diagnostic problems of NTCO Angio-MRI confirms patency of 95% NTCO Depicts tandem lesions
- 8. Diagnostic problems of NTCO Angiography
- 9. NTCO treatment • Guidelines (ESVS) • Clinical trials (NASCET, ECST) – Stroke incidence is low – invasive procedures may be of little benefit BUT after 1 year stroke affects – 6,7% of surgically treated NTCO patients – 11,1% of BMT NTCO patients
- 10. NTCO treatment • BMT • Surgery • Angioplasty + stent
- 11. NTCO revascularisation pros • Stroke risk NTCO > 70-95% stenosis • After procedure stroke risk reduced vs BMT • Periprocedural risk similar to 70-95% stenosis patients • Patients without string sign are more likely to benefit
- 12. NTCO revacularisation - contra • BMT provides fair outcome in this high overall morbidity group of patients • Patients with a string sign are at highest risk but are less likely to benefit
- 13. ECEA BMT
- 15. Conclusion Revascularisation of NTCO should be considered in selected patients •Presenting ipsilateral symptoms •Multivessel occlusive disease •Additional imaging may help identifing patients to benefit from revascularisation – PET – CBF – NIRS
- 16. Challenging case - Endovascular revascularization of occlusion of internal carotid artery Michał Molski1 , Jan Szczepański1 , Wacław Kuczmik2 , Stanisław Molski1 1 Oddział Chirurgii Naczyniowej, Ogólnej I Angiologii, Szpital Eskulap – Centrum Leczenia Chorób Serca i Naczyń 2 Katedra i Klinika Chirurgii Ogólnej i Naczyniowej Śląskiego Uniwersytetu Medycznego
- 17. Female 79 yo Arterial hypertension hyperlipidemia smoker NTCO in DU & angioCT 40% contralateral stenosis CASE #1
- 18. BEFORE CASE #1 AFTER ANGIOPLASTY + STENT
- 19. Follow up Improvement of complaints No neurological symptoms@ 3 months No restenosis@ 3 months CASE #1
- 20. Male 51yo HT CABG Left sided amaurosis Right sided hemiparesis CASE #2
- 21. BEFORE CASE #2 AFTER ANGIOPLASTY + STENT
- 22. Follow-up no clinical symptoms @ 3 months No restenosis @ 3 month CASE #2
Editor's Notes
- TCO is a variable entity, may present as a devastating infarct or be silent. On the other hand many so called asymtomatic patiens present some deficits like: syncopal episodes Retinal caudication progressive loss of visual acuity Limb shaking Unaccustomed headaches ipsilateral brisk pulsations
- large international, randomized clinical trial investigating the efficacy of STA to MCA bypass could not demonstrate a benefit of this procedure over treatment with medication alone Although endovascular procedures have been proven to be technically posiible are lack of data to support this approach.
- Here stands a diagnostic problem to distinguish total occlusion from near-total occlusion. Especially we have to take under consideration w variants – focal and diffuse NTCO. Diffuse stenosis is difficult to visualize flow. In optimal condition US is capable to show flow only in ca 85% cases, that’s why we have to emply other diagnostic modalities problem Is very rare clinical entity ca. 6% of all carotid stenoses Carries very high risk of stroke
- angioCT may reveal flow in some cases and depict colateral network
- angioMR is also superior to US especially in detecting tandem lesions
- Angiography is ultimate imaging modality to visualize stenosis, cloateral network, but brings a !% risk of embolic cerebral complications
- Invasive treatment should be based on morphological criteria, patient cardiovasular risk and experience of a surgeon
- Eversion technique Patch?
- An interesting poin of wiev mey be draw from this paper. Stroke rate after angioplasty is very low, but overall mortality is high due to comorbidities
- Patient complaind of unacastomed headakes and vertigo