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Competitive strategies for surgery in the treatment of primary internal carotid artery (ICA) stenosis

Kompetitive Strategien der Chirurgie bei der Behandlung der primären Carotisstenose

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Zusammenfassung

GRUNDLAGEN: Die Chirurgie hat sich in der Therapie der hochgradigen Karotisstenose als Goldstandard etabliert. In den letzten Jahren wird jedoch vermehrt die endovaskuläre Sanierung mittels perkutaner Angioplastie und Stentimplantation propagiert. Das Ziel dieser Arbeit ist, die Argumente der Proponenten gegen die Chirurgie (größere Belastung für den Patienten, gefährlichere Intervention, höhere Mortalität etc.) näher zu beleuchten und moderne Strategien zu präsentieren, mit welchen die chirurgische Therapie kompetitiv gegen diese Strömungen bestehen kann. METHODIK: Medline (1995–2007) und Cochrane Library Electronic Databases (2007) wurden nach prospektiv randomisierten Publikationen, welche sich mit der chirurgischen und endovaskulären Behandlung der Karotisstenose beschäftigen, durchsucht. Die Resultate dieser Publikationen wurden im Sinne einer Meta-Analyse miteinander verknüpft und in den verschiedenen Domänen (Mortalität, Schlaganfallrate, Komplikationsrate, Krankenhausaufenthalt und Kosten) verglichen. Daraus wurden mögliche Strategien für eine erfolgreiche und komplikationsarme Karotisintervention abgeleitet. ERGEBNISSE: Während die chirurgische Behandlung der Karotisstenose durch große randomisierte Multicenterstudien ihren Stellenwert in der Therapie dieser Erkrankung bereits bewiesen hat, sind diesbezügliche Daten seitens der Karotisstentung noch nicht Level I basiert. Studien, welche Karotisoperation mit Karotisstentung direkt verglichen haben, mussten teilweise wegen vermehrten Auftretens von neurologischen Komplikationen im Stentarm vorzeitig abgebrochen werden. Derzeit gibt es keinen prospektiv randomisierten Vergleich der die Stentbehandlung im Vorteil gegenüber der chirurgischen Therapie sieht. SCHLUSSFOLGERUNGEN: Die Eversionsendarterektomie der Karotisstenose in Lokoregionalanästhesie erfüllt die Ansprüche eines modernen und kompetitiven operativen Konzepts. Sie kann rasch, sicher und einfach durchgeführt werden. Zudem ist das operative Verfahren billig und der Krankenhausaufenthalt limitiert. Die interventionelle Therapie stellt lediglich bei Rezidivstenosen und hostilem Hals eine Alternative zur Operation dar.

Summary

BACKGROUND: Surgery remains the gold standard in the treatment of internal carotid artery (ICA) stenosis. In the last 10 years endovascular treatment of ICA lesions by carotid artery stenting (CAS) has become increasingly popular. The aim of this study is to assess the arguments of carotid endarterectomy (CEA) adversaries (increased physical stress for the patient, complicated procedure, higher mortality, etc.) and to present modern strategies, by which CEA as competitive treatment modality is able to withstand the current trend towards endovascular management of ICA stenosis. METHODS: Medline (1995–2007) and Cochrane Electronic Databases (2007) were searched for prospectively randomized publications, dealing with surgical and endovascular treatment of ICA stenosis. The results have been evaluated in terms of a meta-analysis and compared according to their different domains (mortality, stroke rate, complications, hospital stay, and costs). Corresponding to these data strategies for successful and safe carotid surgery have been developed. RESULTS: Whereas CEA has proved its efficacy in the treatment of ICA stenosis by large randomized multicenter trials, same Level I data are lacking on endovascular management. Some studies comparing CEA with CAS had to be terminated prematurely because of significant higher rates of neurological complications in the CAS arm. At present there exist no prospectively randomized trials which favour CAS over CEA. CONCLUSIONS: Eversion CEA as fast, safe, relatively easy, and economic procedure in locoregional anesthesia fulfils most demands of modern and competitive surgery. Additionally the length of hospital stay can be reduced significantly. Endovascular treatment of ICA stenosis represents an alternative to CEA only in patients with recurrent ICA stenosis and with hostile necks.

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  1. Department of Vascular and Endovascular Surgery, St. Johann Hospital and Paracelsus Private Medical School, Salzburg, Austria

    K. Linni, N. Mader & Th. Hölzenbein

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Linni, K., Mader, N. & Hölzenbein, T. Competitive strategies for surgery in the treatment of primary internal carotid artery (ICA) stenosis. Eur Surg 40, 227–238 (2008). https://doi.org/10.1007/s10353-008-0429-6

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