Der Radiologe

, Volume 53, Issue 3, pp 246–250

Karotisstents – eine Standortbestimmung

Leitthema
  • 299 Downloads

Zusammenfassung

Klinisches/methodisches Problem

Neben der präzisen Graduierung von Karotisstenosen ist insbesondere die Differenzierung in symptomatische und asymptomatische Stenosen wichtig für die Therapieplanung.

Radiologische Standardverfahren

Bei der Behandlung der Karotisstenose ist bei ausgewählten Patienten die Stentbehandlung als gleichwertige Alternative zur „carotid endarterectomy“ (CEA) anzusehen.

Methodische Innovationen

Das „carotid artery stenting“ (CAS) hat sich als eine gering invasive Alternative zur Operation etablieren können, insbesondere weil durch wachsende Erfahrung, technische Innovationen und externe Qualitätssicherung die Komplikationsrate stetig reduziert werden konnte.

Leistungsfähigkeit

Voraussetzung ist die Durchführung des CAS in Zentren mit nachweislich geringer Komplikationsrate von < 3 % bei asymptomatischen und < 6 % bei symptomatischen Stenosen.

Bewertung

Hinsichtlich der Sekundärprophylaxe zeigen sich CAS und CEA als gleich effektiv.

Empfehlung für die Praxis

Idealerweise sollte die Therapieentscheidung interdisziplinär getroffen werden. Bei asymptomatischen Stenosen sind revaskularisierende Maßnahmen insgesamt kritisch zu prüfen, da unter einer optimierten konservativen Therapie wohl nur ein geringes Ischämierisiko besteht.

Schlüsselwörter

Angioplastie Karotisstenose Endarteriektomie Schlaganfallprävention Stentimplantation 

Carotid artery stenting – an update

Abstract

Clinical/methodical issue

Therapy of carotid stenosis should be based on an accurate assessment of the stenosis and a differentiation between symptomatic and asymptomatic patients.

Standard radiological methods

According to current guidelines carotid artery stenting (CAS) can be considered as an established therapeutic alternative to carotid endarterectomy (CEA).

Methodical innovations

For the therapy of carotid stenosis CAS has become established as a minimally invasive alternative to CEA because the complication rate has been reduced due to growing experience, technical innovations and external quality assessment.

Performance

The CAS procedure should be performed in centers with documented complication rates of < 3 % for asymptomatic and < 6 % for symptomatic stenoses.

Achievements

Overall there are no significant differences between CAS and CEA in the treatment of carotid stenosis concerning the secondary prophylactic effect.

Practical recommendations

Ideally an interdisciplinary approach should be chosen for the therapy regime. Revascularization of asymptomatic stenoses should be considered critically as these patients might profit from optimized conservative medicinal therapy.

Keywords

Angioplasty Carotid artery stenosis Endarterectomy Stroke prevention Stent deployment 

Literatur

  1. 1.
    Arning C, Widder B, Reutern GM von et al (2010) Ultraschallkriterien zur Graduierung von Stenosen der A. carotis interna. Revision der DEGUM-Kriterien und Transfer in NASCET-Stenosierungsgrade. Ultraschall Med 31:251–257CrossRefPubMedGoogle Scholar
  2. 2.
    Bangalore S, Kumar S, Wetterslev J et al (2010) Carotid artery stenting vs carotid endarterectomy: meta-analysis and diversity-adjusted trial sequential analysis of randomized trials. Arch Neurol 68:172–184CrossRefPubMedGoogle Scholar
  3. 3.
    Bonati LH, Jongen LM, Haller S et al (2010) New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy of the International Carotid Stenting Study (ICSS). Lancet Neurol 9:353–362CrossRefPubMedGoogle Scholar
  4. 4.
    Brooks WH, McClure RR, Jones MR et al (2004) Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis: a randomized trial in a community hospital. Neurosurgery 54:318–324CrossRefPubMedGoogle Scholar
  5. 5.
    Brott TG, Hobson RW, Howard G et al (2010) Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 363:11–23CrossRefPubMedGoogle Scholar
  6. 6.
    Collaborators N (1991) Benefical effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 325:445–453CrossRefGoogle Scholar
  7. 7.
    Ederle J, Dobson J, Featherstone RL et al (2010) Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 375:985–997CrossRefPubMedGoogle Scholar
  8. 8.
    Ederle J, Featherstone RL, Brown MM (2009) Randomized controlled trials comparing endarterectomy and endovascular treatment for carotid artery stenosis: a Cochrane systematic review. Stroke 40:1373–1380CrossRefPubMedGoogle Scholar
  9. 9.
    Executive committee for the asymptomatic carotid atherosclerosis study (1995) Endarterectomy for asymptomatic carotid artery stenosis. JAMA 273:1421–1428CrossRefGoogle Scholar
  10. 10.
    European Carotid Surgery Trialists‘ Collaborative Group (1998) Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 351:1379–1387CrossRefGoogle Scholar
  11. 11.
    Fairhead JF, Mehta Z, Rothwell PM (2005) Population-based study of delays in carotid imaging and surgery and the risk of recurrent stroke. Neurology 65:371–375CrossRefPubMedGoogle Scholar
  12. 12.
    Gray WA, Rosenfield KA, Jaff MR et al (2011) Influence of site and operator characteristics on carotid artery stent outcomes: analysis of the CAPTURE 2 (Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events) clinical study. JACC Cardiovasc Interv 4:235–246CrossRefPubMedGoogle Scholar
  13. 13.
    Gurm HS, Yadav JS, Fayad P et al (2008) Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med 358:1572–1579CrossRefPubMedGoogle Scholar
  14. 14.
    Halliday A, Mansfield A, Marro J et al (2004) Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 363:1491–1502CrossRefPubMedGoogle Scholar
  15. 15.
    Marquardt L, Geraghty OC, Mehta Z et al (2010) Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Stroke 41:e11–e17CrossRefPubMedGoogle Scholar
  16. 16.
    Mas Jl, Chattelliere G, Beyssen B et al (2006) Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 355:1660–1671CrossRefPubMedGoogle Scholar
  17. 17.
    Meier P, Knapp G, Tamhane U et al (2010) Short term and intermediate term comparison of endarterectomy versus stenting for carotid artery stenosis: systematic review and meta-analysis of randomised controlled clinical trials. BMJ 340:c467CrossRefPubMedGoogle Scholar
  18. 18.
    Petty G, Brown R, Whisnant J et al (1999) Ischemic stroke subtypes: a population-based study of incidence and risk factors. Stroke 20(12):2513–2516CrossRefGoogle Scholar
  19. 19.
    Reiff T, Stingele R, Eckstein HH et al (2009) Stent-protected angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy: SPACE2 – a three-arm randomised-controlled clinical trial. Int J Stroke 4:294–299CrossRefPubMedGoogle Scholar
  20. 20.
    Ringleb PA, Allenberg J, Bruckmann H et al (2006) 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 368:1239–1247CrossRefPubMedGoogle Scholar
  21. 21.
    Silvestrini M, Vernieri F, Pasqualetti P et al (2000) Impaired cerebral vasoreactivity and risk of stroke in patients with asymptomatic carotid artery stenosis. JAMA 283:2122–2127CrossRefPubMedGoogle Scholar
  22. 22.
    Yadav JS, Wholey MH, Kuntz RE et al (2004) Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 351:1493–1501CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  1. 1.Abteilung für Neuroradiologie, Universitätsklinikum ErlangenFriedrich-Alexander-Universität Erlangen-NürnbergErlangenDeutschland

Personalised recommendations