Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3751_Библиотеки_им_академика_М_И_Перельмана
.pdf
b. Flowvelocities andwave tracings are helpful, indeterminingboththe degreeofstenosis andthe
degreeofflowalterationinanygivenpatient.
4.DUSassessmentcanbelimitedwhenthepatienthassignificantcalcificationsatthecarotidbifurcation
aswellasinpatientswhoarelargeinsizewitha“shortneck”orinwhomthecarotidbifurcationishigh
—abovethemandibularangle,makingaccesstothecarotidbifurcationdifficult.
B.ComputedTomographicAngiography
1.Computedtomographicangiography(CTA)hasbecometheprimarycross-sectionalimagingmodality
forsuspectedanatomiclesionsoftheextracranialcarotidandvertebralarteriesincludingclinicalsettings
suchastrauma,stableatherosclerosis,andstroke(Fig.3.2).
2
2.Ionizingradiationandiodinatedcontrastarebothrequired.
3.ModernCTscannersacquireexcellentimageswhileminimizingcontrastandradiationdosages.
a. Most commonly, conventional CTA includes static images performed in the arterial phase with
filmingoftheheadandneckwiththesamecontrastbolus.Inpractice,reconstructionprotocolsvary,
but generally include axial, coronal, sagittal, and oblique images with or without 3D volume
renderedorvesseltrackingimaging.
b. ApplicationofdualenergytechniquesforCTAacquisitionallowsforautomatedboneremovaland
plaquecharacterizationusingthedifferentenergyspectrumforevaluation.
3
c. Newertime-resolvedormultiphasicCTAwithrapidsequentialimagingallowsforvisibledepiction
offlowwithinthevessel,analogoustodigitalsubtractionangiography.
4
4.CTperfusiontechniquesmaybeadjunctiveintheassessmentofthesignificanceofcarotidstenosisor
thesignificanceofanintracranialstenosis.
5
C.MagneticResonanceAngiography
1. Magnetic resonance angiography (MRA) time-of-flight imaging has the advantages of requiring no
ionizingradiationandnointravenouscontrastadministrationtoobtainimagingofthecarotidartery(Fig.
3.3).
6
2. There are some patients who cannot undergo MRI or who may require special monitoring (ie,
pacemakersorimplantedcardioverter-defibrillators).
a. Metallicoralimplants(includingclipsanddentalhardware)maycreatesignificantimagingartifacts
atthelevelofthecarotidarteries,precludingadequatevesselevaluation.
3. Noncontrasttime-of-flightMRA is anexcellent screening tool for cervical or intracranial vascular
diseasebuthasthesignificantdisadvantagethatahigh-gradestenosismayappearasanocclusionunless
contrastMRAisemployed.
4. Contrast MRA improves the visualization of a tiny residual vascular lumen, permitting accurate
differentiationofhigh-gradestenosisversusocclusion.
5.MRApredominantlyimagesthelumenofthevessel;however,evaluationofsourceimagesmayallow
forplaquecharacterization,particularlywhenthinsectionhigh-resolutionimagingalgorithmsareapplied.
a. Suchthinsectionhigh-resolutionimagingalgorithmsarereferredtoasvesselwallimagingorblack
https://t.me/med1917
bloodimagingandarethesubjectofcurrentresearch.7,
8
6.Time-resolvedMRAtechniquesarealsousefulprimarilyforassessmentofarteriovenousshuntingand
fistulouslesions.Thesearelesscommonlyemployedforcervicalvasculardisease.
D.DigitalSubtractionAngiography
1.Digitalsubtractionangiography(DSA)utilizesconventionalx-raywithdigitalacquisitionofimagesin
rapidsequenceduringintra-arterialinjectionofcontrast.
a. Thisprovideshigh-resolution,time-resolved vascularimaging with bothanatomicdelineation and
real-timephysiologicdepictionofflowdynamics(Fig.3.4).
2.DSAisaninvasivetechniquerequiringcatheteraccessusuallyviafemoral,radial,orbrachialroutes,
althoughdirectcarotidaccessmaybeemployedinselectcases.
3.Rotationaldigitalacquisitionpermitscreationof3Dvolumerenderedimages.DSAremainsthegold
standardforDUS,CTA,andMRI/MRA.
9
II.CervicalCarotidandVertebralDisease
Evaluationofcervicalextracranialvasculardiseasebeginswiththevesseloriginsfromtheaorticarch.
Theinnominatearteryarisesfromtheaorticarchanddividesintotherightcommoncarotidarteryandthe
rightsubclavianartery,fromwhichtherightvertebralarteryarises.Theleftcommoncarotidarteryarises
as the next branchfrom the archandfinallythe leftsubclavian, which gives rise to theleft vertebral
artery.Thecommoncarotidarteriesdivideintointernalandexternalcarotidarteriesinthemidcervical
region usually betweenC2 and C6,and thelevel may vary from one side tothe other.Thevertebral
arteriesproceedcranially,traversingtheforamentransversariumofthecervicalvertebraextendingtothe
C2level andaround thearch ofC1until thearteriesentertheduraattheforamenmagnumandjointo
formthebasilararterysuperiorly10(Fig.3.5;Table3.1).
III.AtheroscleroticDisease
A.CausesofIschemicStroke
1. Extracranial carotid artery disease is one of the leading causes of ischemic stroke accounting for
approximately10%ofallischemicstrokes.
2. Carotid artery revascularization in the setting of extracranial atherosclerotic disease, with either
carotid endarterectomy(CEA) or carotid arterystenting (CAS), is now well-established treatmentfor
symptomaticandasymptomaticcarotidatheroscleroticdiseaseinspecificpatients.
11
3.Asnoteverypatientwithextracranialcarotidarteryatheroscleroticdiseasecarriesthe sameriskof
future stroke, key risk factors should be considered to determine which specific patients should be
revascularized.
B.RiskFactors
1. Major riskfactors include the degree of stenosis and characteristics of the plaque seen withinthe
https://t.me/med1917
artery.
2.Otherpatient-specificcharacteristicsincludeage,gender,andcomorbidmedicalconditions.
C.ModalityforRevascularization
1.Thechoiceofmodalityforrevascularizationisbasedonacombinationofthesekeyriskfactorsand
anatomicconsiderations.
2. We review recent trial evidence surrounding carotid revascularization in both symptomatic and
asymptomaticcarotidarterydisease,andthedatasupportingpatientselectionforeachmodality.
3.Afewdefinitionsareimportanttoknowtounderstandandcomparethetrialdata.
D.DefiningCarotidArteryStenosis
1.In theNorthAmericanSymptomaticCarotidEndarterectomyTrial(NASCET),auniformmethodfor
measurement of percentage carotid stenosis at angiography was defined by comparing the minimal
residuallumenat thelevel ofthe stenotic lesion withthe diameter of the more distal internal carotid
arteryatwhichthewallsofthearteryfirstbecomeparallel(beyondanypoststenoticdilatation).
2.Thefollowingformulaisused:Degreeofstenosis=(1−A/B)×100%.
a. AisthediameteratthepointofmaximumstenosisandBisthediameterofthearterialsegmentdistal
tothestenosiswherethewallsfirstbecomeparallel.
12
b. ThismethodofmeasurementhasbeenadaptedtoCTangiography.
c. It is routinely used to define carotid stenosis in current and ongoing trials. Bartlett et al 2006
proposed using the narrowest measurement of the lumen in millimeters stating that an absolute
measurementof1.3mmcorrespondedto70%stenosisbyNASCETcriteriaand2.2mmto50%
13
(Fig.3.6).
E.SymptomaticVersusAsymptomaticExtracranialCarotidStenosis
1. Symptomatic extracranial carotid arterystenosis is defined as an atherosclerotic lesionof atleast
50%stenosisproximaltothevascularterritorythatcorrespondstothepatient’sclinicalsymptomatology
(strokeortransientischemicattack)and/ortheanatomiclocationoftheinfarctonimaging.
2. Atherosclerotic stenosis of the carotid artery may result in ischemic symptoms secondary to
hypoperfusionorembolization.
3.Asymptomaticextracranialcarotid arterystenosisis definedas anatheroscleroticlesionofatleast
50%stenosiswithoutclinicalorimagingevidenceofstroke.
4. Currently, itis recommendedthat bestmedical managementshould be implementedimmediatelyin
bothsymptomaticandasymptomaticatheroscleroticcarotiddiseasewheneveritisfirstdiscovered.14,
15
a. Bestmedicalmanagementinvolvesvascularriskfactormodificationandincludesaggressivecontrol
of hypertension, hyperlipidemia, diabetes mellitus, smoking cessation, and initiation of an
antiplateletagent.
16
IV.RevascularizationinExtracranialCarotidArteryStenosis
https://t.me/med1917
A.Evidence
1.Thereissubstantialevidencetosupportrevascularizationforsymptomaticextracranialcarotidartery
disease. Many large randomized trials including the European Carotid Surgery Trial (ECST), the
NASCET, and the US Department of Veteran Affairs Cooperative Study Program (CSP) showed
superiorityofcarotidendarterectomywithbestmedicalmanagementoverbestmedicalmanagementalone
forsymptomatic,high-gradecarotidarterystenosis.12,17,
18
2. Patients included in these studies were those with greater than 70% carotid artery stenosis on
angiographyandwhohadipsilateralischemicstrokes, monocularblindness, orsymptomsofatransient
ischemicattack.
3.Apooledanalysisfromthesetrialsshowedthattherateof30-daystrokeriskwaslowerinthesurgical
groupcomparedwiththemedicalgroup.
4.TheNASCETstudyspecificallyshowedthatthenumberneededtotreatwithcarotidendarterectomy
wassixforpatientswithsymptomatichigh-gradecarotidarterystenosis.
5.Thestudiesalsoshowedthatforpatientswithlessthan50%stenosisofthecarotidartery,surgerydid
notsignificantlylowerthefuturestrokerisk.
6.Forsurgicalpatientswith50%-69%stenosisintheNASCETstudy,therewasonlymoderatebenefitto
reducestrokerisk,astherateofipsilateralstrokewas15.7%inthosesurgicallytreatedcomparedwith
22.2%inthemedicalgroup.
12
B.Benefits
Bothcarotidendarterectomyandcarotidarterystentinghavebeenshowntobebeneficialinthesettingof
significantstenosisoftheextracranialcarotidarteryinthesettingofatheroscleroticdisease.
C.TrialsandStudies
1.SAPPHIRE
The first trial, Stenting and Angioplasty with Protection in Patients with High Risk of
Endarterectomy (SAPPHIRE) trial showed noninferiority of carotid artery stenting compared with
carotidendarterectomy.
19
2.CREST
Subsequently, the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)
randomlyassignedpatientswithsymptomaticorasymptomaticcarotidstenosistoundergoeithercarotid
arterystentingorcarotidendarterectomy.
11
a. Theprimarycompositeendpointwasstroke,myocardialinfarction,ordeathfromanycauseduring
theperiproceduralperiodoranyipsilateralstrokewithin4yearsafterrandomization.
b. Theresultsofthistrialshowedthattherisksdidnotdiffersignificantlybetweenthecarotidartery
stentinggroupandthecarotidendarterectomygroup.
c. Becauseoftheresultsofthistrial,carotidarterystentingemergedasoneoftheprimarytreatments
forcarotidarteryatheroscleroticdiseaseinselectpatients.
3.ACES
https://t.me/med1917
The Asymptomatic Carotid Emboli Study (ACES) demonstrated that there was a higher risk of
ipsilateral stroke risk with embolic signals on transcranial Doppler (TCD) ultrasound than in those
without,suggestingthatpatientswithasymptomaticcarotiddiseaseshouldundergoTCDtoevaluatefor
microemboli.
20
4.EndarterectomyforAsymptomaticCarotidStenosisStudy
Revascularization for asymptomatic carotid disease was studied in the Endarterectomy for
AsymptomaticCarotidStenosisStudy.21,
22
a. Thisstudywas a large-scalestudy, including1662patients, andcomparedcarotidendarterectomy
withbestmedical managementwithbestmedicalmanagementalone.CTangiographywas usedto
identifypatientswithgreaterthan60%stenosisoftheextracranialcarotidartery,usingtheNASCET
Criteriaformeasurementofcarotidstenosis.
b. Patients were randomly assigned to either surgery plus best medical management or medical
managementalone.
c. Acompositeprimaryoutcomeofstrokeordeathoccurringintheperioperativeperiodandipsilateral
cerebralinfarctionwasused.
d. Thisstudywasstoppedearly,givenevidenceofaclearbenefitinthecarotidendarterectomygroup.
e. ThesedatawerefurthersupportedbytheAsymptomaticCarotidSurgeryTrial(ACST).
23
5.Thesestudiesarenotthoughttobegeneralizabletomodernclinicalpracticebecauseoptimalmedical
therapyhasimprovedinthecurrenteraascomparedwiththetimeofthesestudies(2004-2010).24,
25
6. Furthermore, operators selected for these trials were carefully screened and generally had lower
complicationratesthanwhatwasseeninthegeneralnonstudysurgeonpopulation.
7. Currently, there are no definitive guidelines for revascularization for asymptomatic extracranial
carotidstenosis.
a. However, based on data from these studies and clinical practice, it is reasonable to consider
revascularization in asymptomatic patients with greater than 70%-80% stenosis in the following
typesofpatients:
Patients whose carotid artery stenosis continues to progress rapidly despite best medical
management
PatientswhohaveevidenceofmicroemboliwithTCD
Patientswithalowpotentialforperiproceduralcomplications
b. ThistopicisbeingfurtherinvestigatedintheCarotidRevascularizationandMedicalManagement
forAsymptomaticCarotidStenosis(CREST-2)study,whichiscomparingbestmedicalmanagement
alonewithcarotidendarterectomyorcarotidarterystenting.
26
V.PatientFactorsInfluencingRevascularization
A.NASCET
1. TheNASCET also showed that patientcharacteristics includingage, gender,andcomorbid medical
conditions should stronglyinfluencethe type ofrevascularization procedurethata patientwith carotid
arterydiseaseshouldundergo.
2. Notably,NASCETshowedthatwomenwithsymptomaticcarotidstenosiswere morelikelytohave
https://t.me/med1917
unfavorableoutcomeincludingcarotidarteryrestenosis,surgicalmortality,andneurologicmorbiditywith
carotidarterystenting.
12
B.CREST
1.Nearlyadecadelater,theCRESTprovidedfurtherevidenceregardingspecificpatientcharacteristics
thatshouldinfluencethechoiceofrevascularizationmethod.
2.CRESTshowedthatduringtheperiproceduralperiod,therewasahigherriskofstrokewithcarotid
arterystentingandahigherriskofmyocardialinfarctionwithcarotidendarterectomy.
a. Therefore, patients with significant comorbid coronary artery disease or other cardiovascular
conditionsmaybebettercandidatesforCASratherthanCEA.
11
3.Thestudyalsosupportedpriordatathatpatientageshouldbefactoredintotheproceduralselection
becauseyounger patients, less than70 years, were shown tohave better outcomes withCASwhereas
olderpatientsmayhavehadbetteroutcomeswithCEA.
a. There may be a higher risk of stroke with CAS in very elderly patients because of acquired
anatomicalobstaclessuchasvasculartortuosity,calcifications,and/ortandemstenoses.
b. In general, CAS is preferred in patients with severe comorbid medical condition and those with
anatomic features that would make surgery difficult, including prior neck surgery or radiation
therapy,restenosisafterpriorcarotidendarterectomy,contralateralcarotidocclusion,orsurgically
inaccessiblelesions.
27
VI.TimingofRevascularization
A.TrialsandTrends
1. Timing ofcarotid arteryrevascularization inpatients withischemic stroke remains very important.
Review ofsubgroupanalysesfromtwolargerandomizedclinicaltrials,theEuropeanCarotid Surgery
Trial (ECST)andthe NASCET, lookedat thetiming foroptimal benefitof carotid endarterectomyfor
patients with ischemic stroke thought to be secondary to high-grade symptomatic extracranial carotid
arterydisease.
2.TherewasatrendtowardbenefitwithCEAwithin2weeksofsymptomscomparedwithpatientswho
haddelayedprocedures.12,
28
a. The degree of benefit of the procedure appeared to diminish with time, especially if CEA was
delayedbeyond12weeks.
3. There are manyfactorstoconsider that should influence thetiming ofcarotid revascularizationfor
symptomatic patients including infarct size (as larger ischemic strokes may have a higher risk for
reperfusioninjuryandhemorrhagictransformation)andcomplicatingcomorbiditiesandmedicalfactors
suchasinfectionorhemodynamicinstability.
a. In medically stable patients with relatively minor ischemic strokes or transient ischemic attacks
thought to be secondary tohigh-grade ipsilateral carotid arterystenosis, revascularization should
occurwithin2weeksofsymptomonset.
https://t.me/med1917
b. However,inpatientswithothercomplicatingfactors,itwouldbereasonabletodelaytheprocedure
upto12weekstomedicallystabilizethepatientpriortorevascularization.
B.RestenosisAfterCarotidEndarterectomyorCarotidArteryStenting
1.RestenosisafterCEAorCASistypicallyasymptomaticanddetectedbysurveillanceimaging.
2. The risk of restenosis after carotid intervention was evaluated in the ACAS trial as defined as a
recurrentstenosisof60%orgreater.
a. Theriskofrestenosiswasmostlikelyinthefirst18monthsfollowingsurgery(7.9%)anddeclined
steadilyafterward(1.9%at42months).21CRESTshowedthatapproximately6%ofpatientshada
riskofrestenosisgreaterthan70%inthefirst24monthswitheitherCEAorCAS.
29
b. InCREST,independentpredictorsofrestenosisincludeddiabetesmellitus,hypertension,andfemale
gender.Smokingwasanindependentpredictorofrestenosisinthe CEAgroupbutnotin the CAS
group.
c. Given the low incidence of restenosis after revascularization, there are no standard guidelines
regardingrepeatfollow-upimaginginthesepatients.
11
3.ItisreasonabletofollowpatientsannuallywithDUSforthefirst2yearsfollowingrevascularization,
especially inpatientswith comorbidconditions ofsmoking, diabetes mellitus, hypertension, or female
gender.
C.IntracranialLargeArteryAtheroscleroticDisease
1.Intracraniallargearteryatherosclerosisofthecarotidandvertebralarteriesrepresentsaleadingcause
ofischemicstroke.
2.Therearelimiteddataregardingtreatmentofintercraniallargearteryatherosclerosis.
a. Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial
Stenosis (SAMMPRIS) Study enrolled 451 patients and compared optimal medical therapy with
percutaneous angioplasty and stenting for the prevention of recurrent stroke in patients with
symptomatic intracranial large artery, intracranial carotid, or intracranial vertebral artery
atherosclerosis.
30
i. Medicaltherapyconsistedofdualantiplatelettherapy(aspirin325mgperdayandclopidogrel
75mg perday),aggressive bloodpressurecontroloflessthan140 mmHgandlipid control
withanLDLlessthan70mg/dL,andenrollmentinalifestylemodificationprogram.
ii. The study was terminated early because of a higher 30-day rate of stroke and death in the
percutaneoustransluminalangioplastyandstentingarm.
iii. Therewasastatisticallysignificantdifferenceinstrokeordeath,andtheprimaryendpointof
stroke or death occurred in 5.8% of the medical therapy arm and 14.7% of the
angioplasty/stentingarm.
iv. Thisstudyultimatelyshowedthatpercutaneousstentingisnotsafeoreffectivefortreatmentof
patients who experience a transient ischemic attack or ischemic stroke attributable to large
arteryintracranialdisease.
v. Basedonthemedicaltherapythatwasusedinthisstudy,ifthereisseverestenosisofalarge
intracranialartery(ofgreaterthan50%)withsymptomaticdisease,itisreasonabletoplacethe
patientonaspirinandclopidogrelfor90daysinadditiontohigh-intensitystatintherapywith
https://t.me/med1917
bloodpressurecontrolwithagoalsystoliclessthan140mmHg.
b. TheWarfarin-AspirinSymptomaticIntracranialDiseaseStudy(WASID)evaluated569patientsand
comparedwarfarinwithaspirinfollowingtransientischemicattackorischemicstrokeattributableto
intracranialstenosisoftheinternalcarotidartery,middlecerebralartery,vertebralartery,orbasilar
artery.
31
i. The study was stopped early because of higher rates of death and major hemorrhage inthe
warfarinarm.
ii. Thus,basedonthisstudy,aspirin325mgperdayispreferredtowarfarinforthetreatmentof
symptomaticlargearteryintracranialstenosisandsecondarypreventionofischemicstroke.
iii. Thelong-termfollow-updidshowthatpatientswithameansystolicbloodpressurelessthan
140mmHgandanLDLlessthan100mg/dLhadalowerriskofrecurrentstroke.
D.ExtracranialSymptomaticVertebralArteryDisease
1.Extracranialsymptomaticvertebralarterydiseaseisaknowncauseofposteriorcirculationischemic
infarcts.
2. Treatment options for this disease are limited, and the current mainstay treatment is medical
management.
3.OneofthemostrecentstudiesthatstudiedthiswastheVertebralArteryStentingTrial(VAST),which
evaluatedpatientswithrecenttransientischemicattackorminorstrokeassociatedwithvertebralartery
stenosisofatleast50%.
32
a. Thisstudyevaluatedbothintra-andextracranialvertebralarterydisease.
b. Patientswererandomlyassignedtoeitherstentingplusoptimalmedicaltherapyoroptimalmedical
therapyalone.Thetrialwasultimatelystoppedearlybecauseofregulatoryrequirements.
c. From the analysis of the patients who were enrolled, the authors concluded that stenting of
symptomaticvertebralarterystenosiswasassociatedwithanincreasedriskofmajorperiprocedural
vascularcomplicationandtheriskofrecurrentstrokesinthemedicalmanagementgroupwaslow.
d. However, current guidelines suggest that for recurrent disease vertebral artery stenting, or open
proceduressuchasvertebralendarterectomyortransposition,maybeconsideredinselectpatients
whohaverecurrentischemicstrokesdespitebestmedicalmanagement.33,
34
VII.AdditionalDisordersoftheExtracranialVasculature
A.FibromuscularDysplasia
1.Fibromusculardysplasia(FMD)isadisorderofthemediallayerofthevasculaturethatmanifestsin
analteredappearanceofthenormalvesselluminalcontour.
2. The vessel may demonstrate a thin concentric smooth-walled narrowing, a “string of beads”
appearance,orirregularnarrowing andmaybevulnerable todissection, occlusion,or pseudoaneurysm
formation.
3.EachofthesemaybecomeasourceofembolicausingTIAorstroke.
35
4.FMDcanbeseeninthecervicalcarotidarteriesandcervicalvertebralarteriesandiscommonlyseen
intherenalarteries.
5.ThereisanassociationbetweenFMDandintracranialaneurysms.Angioplastywithorwithoutstenting
hasbeenemployedfortreatmentofFMD-relatedcarotidstenosis(Fig.3.7).
https://t.me/med1917
B.TraumaticCervicalVascularInjury
1.Cervicalvascularinjurycanbedividedintobluntandpenetratingtrauma.
2. CTA hasbeen themainstay ofvascular evaluation inthe settingof facial/mandibular fractures and
cervicalspinefracturesasitcanefficientlyinterrogatebothprimaryandsecondarypathologiclesions.
3. When focusing predominantly on blunt cerebrovascular injury, the cervical vessels (carotid and
vertebral)maydemonstratedissection,with associatedluminalcompromise,vesselocclusion(acuteor
subacute),orpseudoaneurysmformation(oftenadelayedsequelaeofdissection)36(Fig.3.8).
4. Frank vessel rupture is more unusual with blunt cervical injury and is more commonly seen in
associationwithcervicalmalignanciesorinfection(Fig.3.9).
VIII.TechniquesforCarotidandVertebralIntervention
FemoralaccessisthemostcommonaccessrouteforCAS;however,radial,brachial,anddirectcarotid
access may be employed in specific patients to facilitate safe access or traverse an anatomically
challenging artic arch. Femoral arterial access has been presented in an earlier chapter. A brief
description of radial and direct carotid access (percutaneous and via cutdown) can be found in the
sectionsthatfollow.
A.RadialAccessforCarotidStenosis
1.PeripheralarterialaccesstechniquewasfirstintroducedbySvenIvarSeldingerin1959.
37
a. Twodecadeslater,theintroductionofvascularsheathsmadeperipheralaccessmoreappealingby
decreasingtheneedforrepeatedvascularaccessduringpercutaneousvascularprocedures.
b. Twomainarterialaccessesarecommonlyusedformostpercutaneouscarotidarteryinterventions:
thecommonfemoralarteryandradialartery.
c. Directcarotidaccessispreservedforselectivepatients.
2. Lucien Campeau at the Montreal Heart Institute first described transradial access for diagnostic
angiographyofthecoronaryarteriesin1989,asasaferalternativetobrachialoraxillaryaccess.
38
a. Thetransradialaccesswassubsequently,successfullyusedforpercutaneousinterventions,including
thefirsttransradialcoronaryangioplastybyKiemeneijin1992andcoronarystentingin1993.
39
b. Theuseoftransradialaccesstechniquehassignificantlyexpandedinrecentyearsaccountingfor1in
6percutaneouscoronaryinterventions(PCIs)intheUnitedStates.
40
3. Although, thereis abundantliteratureonthetransradialcoronary angiography,dataare emergingon
transradialaccessforcerebralangiographyandstentingforcarotidstenosis.
a. AmulticenterrandomizedstudyhasbyRuzsaetal,hasshownthetransradialapproachforcarotid
stentingtobesafeandwithnodifferenceintotalprocedureandfluoroscopictime.
41
i. The radiation dose was higher, while hospitalization was shorter for radial approach when
comparedwithtransfemoralapproach.
b. Ameta-analysisofrandomizedbyFerranteetalfoundtransradialPCItobeassociatedwithfewer
vascularcomplicationsandalowerrateofmajorbleedinganddeath.
42
i. Furthermore, thetransradial approachhas certainanatomicadvantages over the transfemoral
https://t.me/med1917
approach.
ii. The radial is superficial and easily compressible without major susceptible surrounding
structures,whichsignificantlydecreasepotentialpostprocedurecomplications.39Despitethese
advantages,good patientselection, masteringtechniques,andmeticulouspostprocedural care
arecriticaltominimizepostproceduralcomplications.Asmallradialarterylessthan2mmand
dialysisfistulaconstitutesrelativecontraindications.
39
iii. Bedside tests to evaluate the patency of the palmar arch have not been shown to predict
ischemic complicationsor radialartery occlusion,andthe Allen’s maneuveror Barbeau test
arenolongerrecommendedpriortoradialarteryaccess.
43
4.Themicropuncturetechniqueisoutlinedasfollows.
a. Thewristisplacedinhyperextendedanatomicpositionwitharolledtowelorradialboardusedas
support.
b. Aftergivinglocalanesthesia,theradialarteryispuncturedwitha21-gaugeneedleunderultrasound
guidance.
c. A 0.018-inch wire is advanced through the needle; the needle is then exchanged for a 5 French
coaxial dilator, which is then exchanged over a 0.035-inch Bentson wire for a 4-7 Fr vascular
sheath.
i. Alternativelyspecializedradialarterysheathsareavailablethatcanbeadvanceddirectlyover
an0.018-inchwire.
d. Forpatientsundergoingevaluationofcarotidstenosis,apigtailcatheterisadvancedoveraBentson
wireintotheascendingaorta,andanaortogramisperformed.
i. Further catheter and guidewire selection depends on the side of the carotid stenosis and
anatomicoriginofthegreatvessels.
IX.TechniquesforCarotidArteryStenting
A.AngioplastyandStenting
1.Theearlyapplicationofangioplastyandstentingfortreatmentofcarotidstenosiswasperformedwith
baremetalstentsanalogoustostentplacementinotherperipheralarteries.
2. Thesignificantincidenceofstroke atthetime ofangioplastyandstentingled to the development of
strategiesforembolic protection. Aseriesoftrials were pivotalinthe establishmentofroutine use of
embolicprotectiondevices(EPDs)incarotidangioplastyandstenting.
B.EVA-3STrial
1.In2011,therewasasecondaryanalysisofCASpatientsfromtheendarterectomyversusangioplastyin
patients with symptomatic severe carotid stenosis (EVA-3S) trial (CASvs CEA—France2000-2005),
whichwasstoppedforfutility.
44
a. Inthisstudy262patientsfulfilledtheinclusioncriteria(1wasinitiallyallocatedtosurgery,andin
13patientsstentinsertionfailed).
b. 25patients(9.5%)hadastrokeordeathduringthefirst30dayspostprocedure.
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана