Xử trí khi có hẹp mạch cảnh nặng phối hợp với hẹp mạch vành nặng

Management of Severe Combined Carotid & Coronary Artery Disease Mehdi H Shishehbor, DO, MPH, PhD Director, Endovascular Services Staff, Interventional cardiology and Vascular Medicine 69 Year Old with Unstable Angina and History of Common ILA Stent • CEA plus CABG: – Symptomatic carotid stenosis – Asymptomatic patients with internal carotid stenosis of 80% or more Stroke 12 10 Overall Unilateral 50-99% Bilateral 50-99% Any occlusion Carotid Stenosis & CABG Asymptomatic ≥ 80% stenosis Symptomatic Carotid stenting Hybrid Stent + CABG Staged Stent Followed by CABG CEA Combined CEA + CABG Staged CEA followed by CABG Staged CABG followed by CEA Risk of Death, Stroke, & MI with Combined (CEA + CABG) OR Staged (CEA  CABG) 30 Days Parameter Staged (CEA  CABG) Combined (CEA + CABG)  Any stroke MI    Death/stroke/MI  10 Incidence (%)  15 10 Incidence (%) Naylor AR et al Eur J Vasc Endovasc Surg 2003;25:380-389 15 Staged-Carotid Stent Followed by CABG Death/ Stroke/MI 4/30 Mendiz Events/ Patients 13.3 Ziada 6/56 10.7 Versaci 3/37 8.1 Kovacic 2/20 10.0 Kramer 0/37 0.0 10/85 11.8 31/356 8.7 5/28 17.9 61/649 9.4 Gross Van der Heyden Abbasi Total Heterogeneity p = 0.33 12 % Risk (95% CI) 16 Naylor et al, Eur J Vasc Endovasc Surg 2009;37:379-387 20 30 Day Adverse Events, (%) 35 CS + OHS, (N = 56) 30 25 20 CEA + OHS, (N = 112) 21.6 p = 0.06 15 p = 0.08 p = 0.65 12.6 10.7 9.0 10 p = 0.08 3.3 MI 5.4 7.2 1.8 Stroke Death Death, MI, or Stroke “I strongly recommend against staged or combined CEA in CABG patients with asymptomatic carotid stenosis.” Borger MA , J Card Surg 2005;20:58-59 Limitations of Previous Work • Lack of accounting for interval events like death, MI, or stroke • No direct comparison of three approaches • Outcomes limited to 30-day or in-hospital • Many studies with small sample size and with unadjusted analyses The Cleveland Clinic Experience 1997-2009 Severe Carotid disease in OHS population Carotid Endarterectomy (CEA) Staged CEA-CABG Combined CEA-CABG Carotid Artery stenting (CAS) Staged CAS-CABG Shishehbor et al, JACC 2013 The Cleveland Clinic Experience 1997-2009 Carotid revascularization in Open Heart Surgery (OHS) population (1997–2009) Carotid Endarterectomy (CEA) Carotid Artery Stenting (CAS) 90 days 90 days Staged CEA-OHS Combined CEA-OHS Staged CAS-OHS Shishehbor et al, JACC 2013 Study End Points Interval death, stroke, MI Staged CEA-OHS Combined CEA-OHS Staged CAS-OHS Primary end point: Composite of death, stroke and myocardial infarction (MI) Secondary end points: death, stroke, MI Shishehbor et al, JACC 2013 Statistical Methods Time to event analysis Multiphase hazard function model* Modulated renewal strategy Propensity score adjustment *Blackstone, EH et al Journal of the American Statistical *Association 1986,81:615-624 Results Carotid revascularization and OHS, n=350 CEA, n=45 CAS, n=110 Interval deaths n=3 Interval deaths n=6 OHS n=42 Combined CEA-OHS n=195 OHS n=104 Shishehbor et al, JACC 2013 Baseline Characteristics Staged CEA-OHS n = 45 Combined CEA-OHS n = 195 Staged CAS-OHS n = 110 p value 27 (64) 96 (49) 53 (51) 0.21 History of stroke (%) (21) 39 (20) 36 (35) 0.02 History of TIA (%) (14) 21 (11) 24 (22) 0.01 Ipsilateral carotid symptoms 10 (22) 32 (16) 24 (22) 0.42 Contralateral carotid stenosis 80-99% (%) (4.4) 22 (11) (5.5) 0.02 Contralateral carotid occlusion (%) (16) 24 (12) 13 (12) 0.35 Prior hx of carotid revascularization (%) (11) 13 (6.7) 20 (18)