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
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
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
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
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