Zusammenfassung
Der folgende Artikel fasst die aktuelle Studienlage zur Therapie der asymptomatischen Karotisstenose zusammen und diskutiert deren Evidenzlage in der Literatur. Die 10-Jahres-Ergebnisse der ACST-1-Studie haben gezeigt, dass die Karotisendarteriektomie (CEA) im Vergleich zur konservativen Therapie ihren positiven Langzeiteffekt in der Reduktion jedweder Schlaganfälle beibehalten hat. Alle multizentrisch randomisiert kontrollierten Studien mit dem Vergleich CEA versus Stent (CAS „carotid artery stenting“) und insbesondere die SAPHIRE- und CAVATAS-Studien haben gemeinsam, dass trotz eines grundsätzlichen Evidenzlevels Ib die Fallzahlen der asymptomatischen Patienten für eine stabile Therapieempfehlung zu klein sind. Der in der Gesamtauswertung der CREST-Studie resultierende Unterschied des fraglichen Endpunkts „perioperativer Myokardinfarkt“ zugunsten der CAS-Methode konnte für die ausschließlich asymptomatischen Patienten nicht bestätigt werden. Im Langzeitverlauf der CREST-Studie werden beide Methoden als gleichwertig eingestuft, auch wenn die 4‑Jahres-Ergebnisse der peri- und postprozeduralen Schlaganfallraten in der separaten Auswertung der asymptomatischen Studienteilnehmer eine klare Favorisierung der CEA zulassen. Die Ergebnisse der ACT-1-Studie zeigen einen gleichwertigen Effekt beider Behandlungsmethoden hinsichtlich aller untersuchten Endpunkte. Die ungleiche Gruppengröße lässt jedoch neben der insgesamt statistisch nicht ausreichenden Fallzahl die Aussagefähigkeit dieser Studie hinterfragen. Abzuwarten sind die Ergebnisse der ACST-2- und CREST-2-Studien, die ebenfalls den Stellenwert der „CEA versus CAS“ (ACST-2) sowie „CEA/CAS + BMT (Best Medical Treatment) versus BMT als Single-Therapie“ bei nur asymptomatischen Stenosen untersuchen. Die aktuelle S3-Leitlinie lässt bei Patienten mit einer 60–99 %igen asymptomatischen Karotisstenose die operative Therapie in Erwägung ziehen, da das Schlaganfallrisiko statistisch signifikant reduziert wird.
Abstract
This article summarizes the current study situation on treatment of asymptomatic carotid artery stenosis and discusses the evidence situation in the literature. The 10-year results of the ACST study have shown that in comparison to conservative treatment, carotid endarterectomy (CEA) has retained a positive long-term effect on the reduction of all forms of stroke. All multicenter randomized controlled trials comparing CEA with carotid artery stenting (CAS) and, in particular the SAPHIRE and CAVATAS studies, have in common that despite a basic evidence level of Ib, the case numbers of asymptomatic patients are too small for a conclusive therapy recommendation. In the overall assessment of the CREST study the resulting difference in the questionable endpoint of “perioperative myocardial infarction” in favor of the CAS methods, could not be confirmed for exclusively asymptomatic patients. In the long-term course of the CREST study, both methods were classified as equivalent, even when the 4‑year results of periprocedural and postprocedural stroke rates in the separate assessment of the asymptomatic study participants clearly favored the CEA. The results of the ACST-1 study showed an equivalent effect of both treatment methods with respect to all investigated endpoints; however, the unequal sizes of the groups in addition to the statistically insufficient case numbers put a question mark on the validity of the study results. The results of the ASCT-2 and CREST-2 studies are to be awaited, which also investigate the significance of “CEA versus CAS” (ASCT-2) and “CEA/CAS + best medical treatment (BMT) versus BMT alone” in only asymptomatic stenoses. The current S3 guidelines allow operative therapy to be considered in patients with a 60–99% asymptomatic carotid artery stenosis, because the risk of stroke is statistically significantly reduced.
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S. Demirel, D. Böckler und M. Storck geben an, dass kein Interessenkonflikt besteht.
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Ein Erratum zu diesem Beitrag ist unter http://dx.doi.org/10.1007/s00772-017-0252-0 zu finden.
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Demirel, S., Böckler, D. & Storck, M. Langzeitergebnisse der Karotisendarteriektomie im Methodenvergleich bei asymptomatischer Karotisstenose. Gefässchirurgie 22, 16–23 (2017). https://doi.org/10.1007/s00772-016-0238-3
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DOI: https://doi.org/10.1007/s00772-016-0238-3