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Arq. bras. oftalmol ; 83(5): 417-423, Sept.-Oct. 2020. tab, graf
Article in English | LILACS | ID: biblio-1131620


ABSTRACT Purposes: To evaluate changes in ocular blood flow and subfoveal choroidal thickness in patients with symptomatic carotid artery stenosis after carotid artery stenting. Methods: We included 15 men (mean age, 63.6 ± 9.1 years) with symptomatic carotid artery stenosis and 18 healthy volunteers (all men; mean age, 63.7 ± 5.3 years). All participants underwent detailed ophthalmologic examinations including choroidal thickness measurement using enhanced depth-imaging optic coherence tomography. The patients also underwent posterior ciliary artery blood flow measurements using color Doppler ultrasonography before and after carotid artery stenting. Results: Patients lacked ocular ischemic symptoms. Their peak systolic and end-diastolic velocities increased to 10.1 ± 13.1 (p=0.005) and 3.9 ± 6.3 (p=0.064) cm/s, respectively, after the procedure. Subfoveal choroidal thicknesses were significantly thinner in patients with carotid artery stenosis than those in the healthy controls (p=0.01). But during the first week post-procedure, the subfoveal choroidal thicknesses increased significantly (p=0.04). The peak systolic velocities of the posterior ciliary arteries increased significantly after carotid artery stenting (p=0.005). We found a significant negative correlation between the mean increase in peak systolic velocity values after treatment and the mean preprocedural subfoveal choroidal thickness in the study group (p=0.025, r=-0.617). Conclusions: In patients with carotid artery stenosis, the subfoveal choroid is thinner than that in healthy controls. The subfoveal choroidal thickness increases after carotid artery stenting. Carotid artery stenting treatment increases the blood flow to the posterior ciliary artery, and the preprocedural subfoveal choroidal thickness may be a good predictor of the postprocedural peak systolic velocity of the posterior ciliary artery.

RESUMO Objetivos: Avaliar alterações no fluxo sanguíneo ocular e na espessura da coroide subfoveal em pacientes com estenose sintomática da artéria carótida, após implante de stent nessa artéria. Métodos: Foram incluídos 15 homens (idade média de 63,6 ± 9,1 anos) com estenose sintomática da artéria carótida e 18 voluntários saudáveis (todos homens; idade média de 63,7 ± 5,3 anos). Todos os participantes foram submetidos a exames oftalmológicos detalhados, incluindo d medição da espessura da coroide, usando tomografia de coerência óptica com imagem de profundidade aprimorada. Os pacientes também foram submetidos a medidas do fluxo sanguíneo das artérias ciliares posteriores, usando ultrassonografia com Doppler colorido, antes e após o implante do stent na artéria carótida. Resultados: Os pacientes não apresentaram sintomas isquêmicos oculares. O pico de velocidade sistólica e diastólica final aumentou para 10,1 ± 13,1 (p=0,005) e 3,9 ± 6,3 (p=0,064) cm/s, respectivamente, após o procedimento. As espessuras da coroide subfoveais foram significativamente mais finas nos pacientes com estenose da artéria carótida do que nos controles saudáveis (p=0,01). Porém, durante a primeira semana pós-procedimento, as espessuras das coroides subfoveais aumentaram significativamente (p=0,04). O pico de velocidade sistólica das artérias ciliares posteriores aumentou significativamente após o stent na artéria carótida (p=0,005). Encontramos uma correlação negativa significativa entre o aumento médio dos valores máximos de velocidade sistólica após o tratamento e a espessura da coroide subfoveal pré-procedimento média no grupo de estudo (p=0,025, r=-0,617). Conclusões: Em pacientes com estenose da artéria carótida, a coroide subfoveal é mais fina que a dos controles saudáveis. A espessura da coroide subfoveal aumenta após o stent na artéria carótida. O tratamento com stent na artéria carótida aumenta o fluxo sanguíneo para a artéria ciliar posterior, e a espessura coroidal subfoveal pré-procedimento pode ser um bom preditor da velocidade sistólica de pico pós-procedimento da artéria ciliar posterior.

Humans , Male , Middle Aged , Aged , Ophthalmic Artery , Blood Flow Velocity , Carotid Arteries , Choroid , Regional Blood Flow , Stents , Choroid/anatomy & histology , Choroid/diagnostic imaging , Carotid Stenosis/surgery , Carotid Stenosis/diagnostic imaging , Tomography, Optical Coherence
Rev. bras. cir. cardiovasc ; 35(4): 465-470, July-Aug. 2020. tab
Article in English | SES-SP, LILACS, SES-SP | ID: biblio-1137307


Abstract Objectives: Stroke is an important cause of mortality and morbidity in surgery. In the present study, we examined the cerebral oximetry values of patients with carotid artery stenosis who did not present surgical indications and those who did not present carotid artery stenosis in coronary artery bypass grafting (CABG) surgery by comparing their cerebral oximetry values with cerebrovascular disease (CVD). Methods: Between January and May 2014, 40 patients who underwent isolated CABG were included in the study. Cerebral oximetry probes were placed prior to induction of anesthesia. Cerebral oximetry values were recorded before induction, in the pump (cardiopulmonary bypass) inlet period, in the post-clamp period, in the pump outlet period, and in the intensive care unit and neurological complications. Results: There was no difference between the groups in terms of demographic data and routine follow-up parameters. Intraoperative surgical data and early postoperative results were similar in both groups. When comparing the groups, there were no statistically significant results in cerebral oximetry values and CVD development. Only one patient in group 2 had postoperative CVD and this patient was discharged from the hospital with right hemiplegia. Mean arterial pressure (MAP)levels were significantly higher in Group 2 (P<0.05). Conclusion: The follow-up of cerebral perfusion with a method like near-infrared spectroscopy (NIRS) will ensure that MAP is adjusted with interventions that will be made according to changes in NIRS. Thus, it will be possible to avoid unnecessary medication and flow-rate increase with cerebral oxygen saturation (rSO2) follow-up.

Humans , Male , Female , Middle Aged , Aged , Carotid Stenosis/surgery , Carotid Stenosis/diagnostic imaging , Oxygen , Oximetry , Cerebrovascular Circulation , Coronary Artery Bypass , Spectroscopy, Near-Infrared , Margins of Excision
Chinese Medical Journal ; (24): 2688-2695, 2020.
Article in English | WPRIM | ID: wpr-877836


BACKGROUND@#Metabolic syndrome (MetS) is relatively common worldwide and an important risk factor for cardiovascular diseases. It is closely linked to arterial stiffness of the carotid artery. However, the association of MetS with the safety of carotid revascularization has been rarely studied. The aim of this study was to observe the current status of MetS and its components in Chinese carotid revascularized patients, and investigate the impact on major adverse clinical events (MACEs) after carotid endarterectomy (CEA) or carotid artery stenting (CAS).@*METHODS@#From January 2013 to December 2017, patients undergoing CEA or CAS in the Neurosurgery Department of Xuanwu Hospital were retrospectively recruited. The changes in prevalence of MetS and each component with time were investigated. The primary outcome was 30-day post-operative MACEs. Univariable and multivariable analyses were performed to identify the impact of MetS on CEA or CAS.@*RESULTS@#A total of 2068 patients who underwent CEA (766 cases) or CAS (1302 cases) were included. The rate of MetS was 17.9%; the prevalence rate of MetS increased with time. The occurrence rate of MACEs in CEA was 3.4% (26 cases) and in CAS, 3.1% (40 cases). There was no statistical difference between the two groups (3.4% vs. 3.1%, P = 0.600). For CEA patients, univariate analysis showed that the MACE (+) group had increased diabetes history (53.8% vs. 30.9%, P = 0.014) and MetS (34.6% vs. 15.8%, P = 0.023). For CAS patients, univariate analysis showed that the MACE (+) group had increased coronary artery disease history (40.0% vs. 21.6%, P = 0.006) and internal carotid artery tortuosity (67.5%% vs. 37.6%, P < 0.001). Furthermore, the MACE (+) group had higher systolic blood pressure (143.38 ± 22.74 vs. 135.42 ± 17.17 mmHg, P = 0.004). Multivariable analysis showed that the influencing factors for MACEs in CEA included history of diabetes (odds ratio [OR] = 2.345; 95% confidence interval [CI] = 1.057-5.205; P = 0.036) and MetS (OR = 2.476; 95% CI = 1.065-5.757; P = 0.035). The influencing factors for MACEs in CAS included systolic blood pressure (OR = 1.023; 95% CI = 1.005-1.040; P = 0.010), coronary artery disease (OR = 2.382; 95% CI = 1.237-4.587; P = 0.009) and internal carotid artery tortuosity (OR = 3.221; 95% CI = 1.637-6.337; P = 0.001).@*CONCLUSIONS@#The prevalence rate of MetS increased with time in carotid revascularized patients. MetS is a risk for short-term MACEs after CEA, but not CAS.

Carotid Arteries/surgery , Carotid Stenosis/surgery , China/epidemiology , Endarterectomy, Carotid/adverse effects , Humans , Metabolic Syndrome/epidemiology , Retrospective Studies , Risk Factors , Sample Size , Stents/adverse effects , Stroke , Time Factors , Treatment Outcome
Arq. bras. cardiol ; 111(4): 618-625, Oct. 2018. tab, graf
Article in English | LILACS | ID: biblio-973768


Abstract Severe carotid atherosclerotic disease is responsible for 14% of all strokes, which result in a high rate of morbidity and mortality. In recent years, advances in clinical treatment of cardiovascular diseases have resulted in a significant decrease in mortality due to these causes. To review the main studies on carotid revascularization, evaluating the relationship between risks and benefits of this procedure. The data reviewed show that, for a net benefit, carotid intervention should only be performed in cases of a periprocedural risk of less than 6% in symptomatic patients. The medical therapy significantly reduced the revascularization net benefit ratio for stroke prevention in asymptomatic patients. Real life registries indicate that carotid stenting is associated with a greater periprocedural risk. The operator annual procedure volume and patient age has an important influence in the rate of stroke and death after carotid stenting. Symptomatic patients have a higher incidence of death and stroke after the procedure. Revascularization has the greatest benefit in the first weeks of the event. There is a discrepancy in the scientific literature about carotid revascularization and/or clinical treatment, both in primary and secondary prevention of patients with carotid artery injury. The identification of patients who will really benefit is a dynamic process subject to constant review.

Resumo A doença aterosclerótica carotídea grave é responsável por 14% de todos os acidentes vasculares cerebrais (AVC), que refletem em uma alta taxa de morbimortalidade. Nos últimos anos, os avanços no tratamento clínico das doenças cardiovasculares geraram um decréscimo importante na mortalidade por estas causas. Revisar principais estudos que dizem respeito à revascularização carotídea avaliando a relação entre risco e beneficio deste procedimento. Os dados encontrados indicam que o procedimento só deve ser realizado se houver um risco periprocedimento menor que 6% em pacientes sintomáticos para que haja beneficio líquido na intervenção carotídea. O tratamento clínico reduziu significativamente o benefício líquido da revascularização na prevenção de AVC em pacientes assintomáticos. Registros que refletem a prática diária demonstram que a angioplastia carotídea esta associada a um risco periprocedimento mais elevado. O volume anual de procedimentos por operador e a idade dos pacientes têm uma importante influência nas taxas de AVC e morte pós angioplastia. Pacientes sintomáticos têm uma maior incidência de AVC e morte após procedimento. A revascularização tem o maior benefício nas primeiras semanas do evento. Existem discrepâncias na literatura científica com relação à revascularização carotídea e/ou tratamento clínico, tanto na prevenção primária quanto secundária de pacientes com lesão carotídea. A identificação do paciente que realmente será beneficiado é um processo dinâmico sujeito a constante revisão.

Humans , Stents , Endarterectomy, Carotid/methods , Carotid Stenosis/surgery , Angioplasty/methods , Risk Assessment , Carotid Arteries/surgery , Risk Factors , Treatment Outcome , Carotid Stenosis/complications , Stroke/etiology
Rev. chil. cir ; 70(1): 35-39, 2018. tab
Article in Spanish | LILACS | ID: biblio-899653


Resumen Introducción En la endarterectomía carotídea (EC) durante el clampeo, la perfusión cerebral se mantiene por circulación contralateral a través del Polígono de Willis, que se relaciona con la presión de muñón carotídeo (PM). Si ésta es menor a 50 mmHg existe riesgo de Accidente Cerebrovascular (ACV) por hipoperfusión y está indicado uso de shunt para asegurar suficiente circulación cerebral, pero también se puede elevar transitoriamente la presión arterial sistémica haciendo innecesario el uso de shunt. Objetivo Mostrar los resultados de EC con medición de PM para evaluar la perfusión cerebral del hemisferio clampeado con manejo hemodinámico intraoperatorio minimizando el uso de shunt. Material y Métodos Estudio retrospectivo de 73 pacientes sometidos a EC bajo anestesia general con medición de PM, manejo hemodinámico intraoperatorio y uso selectivo de shunt. Se analizaron variables demográficas, clínicas y morbimortalidad perioperatoria. Resultados 73 pacientes, edad promedio 71,1 años, 69,9% sintomáticos. En 54 pacientes la PM fue superior a 50 mmHg y no se usó shunt, en 19 la PM fue menor a 50 mmHg y con manejo hemodinámico intraoperatorio se elevó en 16 que no requirieron shunt. Sólo en 3 casos la PM no alcanzó los 50 mmHg y se usó un shunt de Pruitt-Inahara. Dos pacientes sintomáticos presentaron déficit neurológico central transitorio postoperatorio y 2 pacientes fallecieron por infarto cardíaco. Conclusión La EC con medición de PM y manejo hemodinámico minimizó el uso de shunt transitorio y fue un procedimiento seguro para tratar los pacientes con estenosis carotídea con indicación quirúrgica.

Introduction During carotid endarterectomy (CEA) clamping cerebral perfusion is maintained by contralateral circulation through the Circle of Willis and it is correlated to the stump pressure (SP). If it is below 50 mmHg there is risk of stroke due to hypoperfusion and a shunt must be used, but systemic blood pressure can be temporarily elevated making the use of shunt unnecessary. Aim Results of CEA with SP measurement to evaluate cerebral perfusion in cross-clamped hemisphere and hemodynamic intraoperative management reducing the use of shunt. Material and Methods Retrospective study of CEAs performed in 73 patients under general anaesthesia with SP measurement, hemodynamic management and selective use of shunt. Demographics, clinical and perioperative morbimortality variables were analized. Results 73 patients, average age 71.1 years, 69.9% symptomatic. In 54 patients SP was above 50 mmHg and shunt was not used, in 19 SP was below 50 mmHg, it was elevated through intraoperative hemodynamic management and shunt was not needed. In only 3 cases SP did not reach 50 mmHg and a Pruitt-Inahara shunt was used. Two patients presented postoperative transient central neurological deficit and 2 died due to myocardial infarction. Conclusion CEA with SP measurement and hemodynamic management reduced the use of carotid shunting and it was a safe procedure to treat patients with severe carotid stenosis who need surgical intervention.

Humans , Male , Female , Middle Aged , Aged , Aged, 80 and over , Blood Pressure , Monitoring, Intraoperative , Endarterectomy, Carotid , Carotid Stenosis/surgery , Carotid Stenosis/physiopathology , Postoperative Complications , Blood Pressure Determination , Arteriovenous Shunt, Surgical , Retrospective Studies , Circle of Willis/physiopathology , Treatment Outcome
Rev. bras. cir. cardiovasc ; 31(5): 365-370, Sept.-Oct. 2016. tab
Article in English | LILACS | ID: biblio-829750


Abstract Objective: This study aims to compare three different surgical approaches for combined coronary and carotid artery stenosis as a single stage procedure and to assess effect of operative strategy on mortality and neurological complications. Methods: This retrospective study involves 136 patients who had synchronous coronary artery revascularization and carotid endarterectomy in our institution, between January 2002 and December 2012. Patients were divided into 3 groups according to the surgical technique used. Group I included 70 patients who had carotid endarterectomy, followed by coronary revascularization with on-pump technique, group II included 29 patients who had carotid endarterectomy, followed by coronary revascularization with off-pump technique, group III included 37 patients who had coronary revascularization with on-pump technique followed by carotid endarterectomy under aortic cross-clamp and systemic hypothermia (22-27ºC). Postoperative outcomes were evaluated. Results: Overall early mortality and stroke rate was 5.1% for both. There were 3 (4.3%) deaths in group I, 2 (6.9%) deaths in group II and 2 (5.4%) deaths in group III. Stroke was observed in 5 (7.1%) patients in group I and 2 (6.9%) in group II. Stroke was not observed in group III. No statistically significant difference was observed for mortality and stroke rates among the groups. Conclusion: We identified no significant difference in mortality or neurologic complications among three approaches for synchronous surgery for coronary and carotid disease. Therefore it is impossible to conclude that a single principle might be adapted into standard practice. Patient specific risk factors and clinical conditions might be important in determining the surgical tecnnique.

Humans , Male , Female , Aged , Coronary Artery Disease/surgery , Coronary Artery Bypass/methods , Endarterectomy, Carotid/methods , Carotid Stenosis/surgery , Stroke/etiology , Coronary Artery Disease/mortality , Coronary Artery Bypass/adverse effects , Retrospective Studies , Treatment Outcome , Endarterectomy, Carotid/adverse effects , Carotid Stenosis/mortality , Combined Modality Therapy , Stroke/mortality
Rev. bras. cir. cardiovasc ; 30(3): 295-303, July-Sept. 2015. tab, ilus
Article in English | SES-SP, LILACS, SES-SP | ID: lil-756525


AbstractObjective:Matrix metalloproteinases are inflammatory biomarkers involved in carotid plaque instability. Our objective was to analyze the inflammatory activity of plasma and carotid plaque MMP-8 and MMP-9 after intravenous administration of hydrocortisone.Methods:The study included 22 patients with stenosis ≥ 70% in the carotid artery (11 symptomatic and 11 asymptomatic) who underwent carotid endarterectomy. The patients were divided into two groups: Control Group - hydrocortisone was not administered, and Group 1 - 500 mg intravenous hydrocortisone was administered during anesthetic induction. Plasma levels of MMP-8 and MMP-9 were measured preoperatively (24 hours before carotid endarterectomy) and at 1 hour, 6 hours and 24 hours after carotid endarterectomy. In carotid plaque, tissue levels of MMP-8 and MMP-9 were measured.Results:Group 1 showed increased serum levels of MMP- 8 (994.28 pg/ml and 408.54 pg/ml, respectively; P=0.045) and MMP-9 (106,656.34 and 42,807.69 respectively; P=0.014) at 1 hour after carotid endarterectomy compared to the control group. Symptomatic patients in Group 1 exhibited lower tissue concentration of MMP-8 in comparison to the control group (143.89 pg/ml and 1317.36 respectively; P=0.003). There was a correlation between preoperative MMP-9 levels and tissue concentrations of MMP-8 (P=0.042) and MMP-9 (P=0.019) between symptomatic patients in the control group.Conclusion:Hydrocortisone reduces the concentration of MMP- 8 in carotid plaque, especially in symptomatic patients. There was an association between systemic and tissue inflammation.

ResumoObjetivo:As metaloproteinases são biomarcadores inflamatórios envolvidos na instabilidade da placa carotídea. O objetivo deste estudo foi analisar a atividade inflamatória da MMP-8 e MMP-9 plasmática e presente na placa carotídea, após administração intravenosa de hidrocortisona.Métodos:Participaram do estudo 22 pacientes portadores de estenose ≥ 70% em artéria carótida (11 sintomáticos e 11 assintomáticos), submetidos à endarterectomia de artéria carótida. Os pacientes foram divididos em dois grupos: Grupo Controle - não foi administrado hidrocortisona e Grupo 1 - foi administrado 500 mg intravenoso de hidrocortisona durante a indução anestésica. As dosagens plasmáticas de MMP-8 e MMP-9 foram efetuadas no pré-operatório (24 horas antes da endarterectomia de artéria carótida) e em 1 hora, 6 horas e 24 horas após endarterectomia de artéria carótida. Na placa carotídea foram mensurados os níveis teciduais de MMP-8 e MMP-9.Resultados:O grupo 1 exibiu elevação dos níveis séricos da MMP-8 (994,28 pg/ml e 408,54 pg/ml, respectivamente; P=0.045) e MMP-9 (106.656,34 e 42.807,69, respectivamente; P=0.014) em 1 hora após a endarterectomia de artéria carótida, em relação ao grupo controle. Os pacientes sintomáticos do grupo 1 exibiram menor concentração tecidual de MMP-8, em relação ao grupo controle (143,89 pg/ml e 1317,36, respectivamente; P=0.003). Houve correlação entre os níveis pré-operatórios de MMP-9 e as concentrações teciduais de MMP-8 (P=0.042) e MMP-9 (P=0.019) entre os pacientes sintomáticos do grupo controle.Conclusão:A hidrocortisona reduz a concentração de MMP-8 na placa carotídea, em especial nos pacientes sintomáticos. Houve associação entre a inflamação sistêmica e a tecidual.

Humans , Male , Female , Middle Aged , Aged , Aged, 80 and over , Anti-Inflammatory Agents/pharmacology , Carotid Artery, Internal/drug effects , Carotid Stenosis/surgery , Hydrocortisone/pharmacology , /drug effects , Matrix Metalloproteinase 9/drug effects , Anti-Inflammatory Agents/therapeutic use , Biomarkers/analysis , Carotid Artery, Internal/enzymology , Carotid Stenosis/enzymology , Endarterectomy, Carotid , Hydrocortisone/therapeutic use , /analysis , Matrix Metalloproteinase 9/analysis , Postoperative Period , Reference Values , Statistics, Nonparametric , Time Factors , Treatment Outcome
Rev. bras. cir. cardiovasc ; 29(4): 574-580, Oct-Dec/2014. tab, graf
Article in English | LILACS | ID: lil-741727


Objective: To analyze the results of 125 carotid endarterectomies under loco-regional anesthesia, with selective use of shunt and bovine pericardium patch. Methods: One hundred and seventeen patients with stenosis ≥ 70% in the internal carotid artery on duplex-scan + arteriography or magnetic resonance angiography underwent 125 carotid endarterectomies. Intraoperative pharmacological cerebral protection included intravenous administration of alfentanil and dexametasone. Clopidogrel, aspirin and statins were used in all cases. Seventy-seven patients were males (65.8%). Mean age was 70.8 years, ranging from 48 to 88 years. Surgery was performed to treat symptomatic stenosis in 69 arteries (55.2%) and asymptomatic stenosis in 56 arteries (44.8%). Results: A carotid shunt was used in 3 cases (2.4%) due to signs and symptoms of cerebral ischemia after carotid artery clamping during the operation, and all 3 patients had a good outcome. Bovine pericardium patch was used in 71 arteries ≤ 6 mm in diameter (56.8%). Perioperative mortality was 0.8%: one patient died from a myocardial infarction. Two patients (1.6%) had minor ipsilateral strokes with good recovery, and 2 patients (1.6%) had non-fatal myocardial infarctions with good recovery. The mean follow-up period was 32 months. In the late postoperative period, there was restenosis in only three arteries (2.4%). Conclusion: Carotid artery endarterectomy can be safely performed in the awake patient, with low morbidity and mortality rates. .

Objetivo: Analisar os resultados de 125 endarterectomias carotídeas, realizadas sob anestesia loco-regional com uso seletivo de shunt e remendo de pericárdio bovino. Métodos: Cento e dezessete pacientes com estenose na artéria carótida interna ≥ 70% ao ecoDoppler colorido + arteriografia ou angiorressonância magnética foram submetidos a 125 endarterectomias carotídeas. As medidas de proteção farmacológica intraoperatória incluíam a administração endovenosa de alfentanil e dexametazona. Clopidogrel, aspirina e estatinas eram utilizadas em todos os casos. Setenta e sete pacientes eram do sexo masculino (65,8%). A idade média foi de 70,8 anos, variando de 48 a 88 anos. A operação foi indicada por estenose sintomática em 69 artérias (55,2%), e por estenose assintomática em 56 artérias (44,8%). Resultados: O shunt de carótida foi necessário em 3 casos (2,4%) devido a sintomas de isquemia cerebral após a colocação do clampe carotídeo durante o ato cirúrgico, e os três pacientes tiveram boa evolução. Remendo de pericárdio bovino foi utilizado em 71 artérias ≤ 6 mm de diâmetro (56,8%). A mortalidade perioperatória foi de 0,8%: um paciente faleceu devido a infarto agudo do miocárdio. Dois pacientes (1,6%) tiveram infartos cerebrais isquêmicos ipsilaterais menores com boa recuperação, e 2 pacientes (1,6%) tiveram infartos do miocárdio não-fatais com boa recuperação. O tempo médio de seguimento foi de 32 meses. No pós-operatório tardio, houve reestenose significativa em apenas três artérias (2,4%). Conclusão: A endarterectomia carotídea no paciente acordado é uma técnica segura, sendo realizada com baixas taxas de morbimortalidade. .

Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Anesthesia, Local/methods , Carotid Artery, Internal/surgery , Carotid Stenosis/surgery , Endarterectomy, Carotid/methods , Wakefulness , Angiography , Constriction , Carotid Artery, Internal , Carotid Artery, Internal , Carotid Stenosis , Carotid Stenosis , Perioperative Care , Pericardium/transplantation , Reproducibility of Results , Retrospective Studies , Stroke/prevention & control , Time Factors , Treatment Outcome , Ultrasonography, Doppler, Color
Rev. bras. cardiol. invasiva ; 21(2): 152-158, abr.-jun. 2013. tab
Article in Portuguese | LILACS | ID: lil-681949


INTRODUÇÃO: O acidente vascular encefálico (AVE) é a principal causa de morbidade e mortalidade no Brasil. Entre 10% e 30% dos AVEs estão associados à doença carotídea e 8%, à artéria vertebral. O tratamento endovascular das lesões extracrania­nas é alternativa à endarterectomia. Analisamos os resultados e avaliamos os preditores de eventos adversos em pacientes submetidos a angioplastia carotídea e vertebral com implante de stents. MÉTODOS: Incluídos assintomáticos com lesão > 70% ou sintomáticos com lesão > 50% em artérias carótidas e sintomáticos com lesão > 70% em artérias vertebrais. Avaliamos desfecho primário, definido como a incidência combinada de morte relacionada ou não ao procedimento, AVE maior, AVE menor ou infarto agudo do miocárdio (IAM). RESULTADOS: Realizadas 224 intervenções com implante de stents em 199 pacientes consecutivos, com predomínio do sexo masculino (73,9%), idade de 69,8 ± 9,9 anos e 37,7% eram diabéticos. Pacientes sintomáticos representaram cerca de dois terços dos casos e as lesões mais tratadas foram as lesões de novo (96,4%). As artérias carótidas internas esquerda (46%) e direita (44,6%) foram os vasos mais abordados. Desfecho combinado primário ocorreu em 5%, mortalidade relacionada ao procedimento em 1%, mortalidade não-relacionada ao procedimento em 1%, AVE menor em 1,5% e IAM em 1,5%. Pacientes com antecedente de doença arterial coronária mostraram chance de apresentar desfecho primário 4 vezes maior [odds ratio (OR) 4,32, intervalo de confiança de 95% (IC 95%) 1,09-17,21; P = 0,038]. CONCLUSÕES: Em nosso estudo obtivemos alto índice de sucesso e baixa ocorrência de eventos adversos, que demonstram a segurança e a eficácia do implante percutâneo de stent em artérias carótidas e vertebrais.

BACKGROUND: Stroke remains the leading cause of morbidity and mortality in Brazil. Epidemiological data suggest that 10% to 30% of all strokes are due to atherosclerotic carotid artery disease and 8% due to vertebral artery disease. Endovascular treatment of extracranial lesions is an alternative to endarterectomy. We evaluated the results and predictors of adverse events in patients undergoing carotid and vertebral artery stenting. METHODS: Asymptomatic patients with lesion > 70% or symptomatic patients with lesions > 50% in carotid arteries and symptomatic patients with lesion > 70% in vertebral arteries were included. We evaluated the primary endpoint, defined as the composite incidence of death (procedural or non-procedural), major stroke, minor stroke or myocardial infarction (MI). RESULTS: Two hundred and twenty-four interventions with stenting were performed in 199 consecutive patients with a prevalence of males (73.9%), 69.8 ± 9.9 years of age and 37.7% were diabetics. Symptomatic patients represented about two thirds of the cases and the most commonly treated lesions were de novo lesions (96.4%). The left (46%) and right (44.6%) internal carotid arteries were the most commonly approached vessels. Composite primary endpoint was observed in 5% of the patients, procedure-related mortality in 1%, non-procedure related mortality in 1%, minor stroke in 1.5% and MI in 1.5%. Patients with a history of coronary artery disease had a 4-fold probability of presenting the primary endpoint [odds ratio (OR) 4.32, 95% confidence interval (CI 95%) 1.09-17.21); P = 0.038]. CONCLUSIONS: In our study we obtained a high success rate and had a low rate of adverse events, demonstrating the safety and efficacy of percutaneous stent implantation in the carotid and vertebral arteries.

Humans , Male , Stroke/complications , Stroke/mortality , Angioplasty/methods , Carotid Arteries/surgery , Carotid Stenosis/surgery , Stents , Endarterectomy/methods , Risk Factors
West Indian med. j ; 62(2): 135-139, Feb. 2013. ilus, tab
Article in English | LILACS | ID: biblio-1045605


BACKGROUND: Recent concerns have been raised about the potential for proton pump inhibitors (PPIs) to blunt the efficacy of clopidogrel. We observed the effect of clopidogrel plus aspirin with or without omeprazole in patients with carotid stenoses after they received placement of carotid stents. METHODS: Sixty-four consecutive patients treated with percutaneous carotid artery stenting (CAS) comprised the sample. All enrolled patients underwent the C13 urea breath test (C13 UBT) before CAS. Patients with Helicobacter pylori infection and a history of peptic ulcer were assigned dual antiplatelet combination with omeprazole. Others received dual antiplatelet without omeprazole. Transcranial Doppler and ultrasonography were performed to assess the middle cerebral artery and carotid artery in follow-up at three months and six months. RESULTS: Eight patients had gastrointestinal bleeding; the event rate was 22.6% without omeprazole and 3.8% with omeprazole. The rate of gastrointestinal bleeding was reduced with omeprazole as compared without omeprazole (p = 0.026, p < 0.05). The two groups did not differ significantly in the rate of instent restenosis and thrombus through transcranial Doppler and ultrasonography. CONCLUSION: Among patients receiving dual antiplatelet therapy, prophylactic use of omeprazole reduced the rate of upper gastrointestinal bleeding. There was no apparent interaction between clopidogrel and omeprazole in patients with carotid artery stenting.

ANTECEDENTES: Recientemente se han expresado preocupaciones acerca de la posibilidad de que los inhibidores de la bomba de protones (IBP) para debilitar la eficacia del clopidogrel. Observamos el efecto del clopidogrel más aspirina con o sin omeprazol en pacientes con estenosis de la arteria carótida después de que recibieran la colocación de stents carotídeos. MÉTODOS: Sesenta y cuatro pacientes consecutivos tratados con stent percutáneo de la arteria carótida (SAC) fueron seleccionados para formar la muestra. A todos los pacientes inscritos se les realizó la prueba de aliento con urea C13 (C13 UBT) antes de CAS. A pacientes con infección por Helicobacter pylori y antecedentes de úlcera péptica les fue asignada una combinación antiplaquetaria dual con omeprazol. Otros recibieron tratamiento antiplaquetario dual sin omeprazol. Se realizaron una prueba Transcranial Doppler y una ultrasonografía a fin de evaluar la arteria cerebral media y la arteria carótida en seguimientos a los tres meses y a los seis meses. RESULTADOS: Ocho pacientes tuvieron hemorragia gastrointerstinal; la tasa de eventos fue 22.6% sin omeprazol y 3.8% con omeprazol. La tasa de hemorragia gastrointerstinal se redujo con omeprazol en comparación con la obtenida sin omeprazol (p = 0,026, p < 0.05). Los dos grupos no difirieron significativamente con respecto a la tasa de restenosis en stent y trombos a través de la prueba Transcranial Doppler y la ultrasonografía. CONCLUSIÓN: Entre los pacientes que reciben terapia antiplaquetaria dual, el uso profiláctico de omeprazol redujo la tasa de hemorragia gastrointestinal superior. No hubo interacción ostensible entre el clopidogrel y el omeprazol en pacientes con stent de la arteria carótida.

Humans , Male , Female , Middle Aged , Omeprazole/administration & dosage , Platelet Aggregation Inhibitors/administration & dosage , Carotid Stenosis/surgery , Clopidogrel/administration & dosage , Gastrointestinal Hemorrhage/prevention & control , Angiography , Carotid Arteries/diagnostic imaging , Stents , Aspirin/administration & dosage , Helicobacter Infections/drug therapy , Drug Interactions , Drug Therapy, Combination
Rev. argent. cir. cardiovasc. (Impresa) ; 10(1): 16-20, ene-abr. 2012.
Article in Spanish | LILACS | ID: lil-730171


Objetivo: No existen diferencias significativas entre pacientes octogenarios y menores de ochentaaños en eventos ACV-Muerte, intervenidos por estenosis carotídea mediante endarterectomía carotídea.Material y Métodos: Desde enero de 2006 hasta junio de 2010 se realizaron 253 endarterectomías carotídeas en 251 pacientes, 24 (9.56%) (IC95% 6.21-13.90) pacientes tenían más de 80 años. Resultados: Del total de las endarterectomías carotídeas realizadas en pacientes menores de 80 años, 4 presentaron ACV y 1 falleció en el perioperatorio (ACV-muerte (n=5/227) (2.2%) (IC 95% 0.71-5.07)). Un paciente presentó un infarto agudo de miocardio perioperatorio en este grupo(0.4%) (IC 95% 0.006-2.43). De los 24 octogenarios, 1 paciente presentó ACV perioperatorio, dando un índice de ACV-muerte de 4.16 % (n=1) (IC 95% 0.05-21.14). Al comparar la poblaciónde ambos grupos no se hallaron evidencias significativas en la aparición de eventos adversos mayores como ACV o muerte que contraindiquen la cirugía en pacientes octogenarios con significación estadística p=0.91.Conclusión: En la muestra estudiada, no existen diferencias significativas entre pacientes octogenarios y menores de ochenta años en eventos ACV-Muerte postoperatoria, intervenidos porestenosis carotidea.

Objetivo: Não existem diferenças significativas entre pacientes octogenários e pacientes menores de oitenta anos em eventos ACV-Morte, operados por estenose carotídea mediante endarterectomia carotídea.Material e Métodos: De janeiro de 2006 a junho de 2010 realizaram-se 253 endarterectomias carotídeas em 251 pacientes, 24 (9.56%) (IC 95% 6.21-13.90) pacientes tinham mais de 80 anos. Resultados: Do total das endarterectomias carotídeas realizadas em pacientes menores de 80 anos, 4 apresentaram ACV e 1 faleceu no perioperatório (ACV-morte (n: 5/227) (2.2%) (IC 95% 0.71-5.07)). Neste grupo, um paciente apresentou um infarto agudo de miocárdio perioperatório (0.4%) (IC 95% 0.006-2.43). Dos 24 octogenários, 1 paciente apresentou ACV perioperatório, dando um índice de ACV-morte de 4.16 % (n=1) (IC 95% 0.05-21.14). Ao comparar a população dos dois grupos, não se encontraram evidências significativas no aparecimento de eventos adversos maiores como ACV ou morte, que contraindiquem a cirurgia em pacientes octogenários com estatística significativa p=0.91. Conclusão: Na amostra estudada, não existem diferenças significativas entre pacientesoctogenários e pacientes menores de oitenta anos em eventos ACV-Morte pós operatória, operados por estenose carotídea.

Objective: There are no significant differences between octogenarians and younger patients than eighty years in stroke-death events, with surgery for carotid stenosis by carotid endarterectomy. Material and Methods: From January 2006 through June 2010 were 253 carotid endarterectomiesin 251 patients, 24 (9.56%) (95% CI 6.21-13.90) were older than 80 years.Results: Of all carotid endarterectomies performed in patients younger than 80 years, 4 patients had a stroke and died in the perioperative patient (stroke-death (n=5/227) (2.2%) (95% CI 0.71-5.07)). One patient had a perioperative myocardial infarction in this group (0.4%) (95% CI 0.006-2.43). Of the 24 octogenarians, 1 patient had perioperative stroke, giving a rate of stroke-death of 4.16% (n=1) (95% CI 0.05-21.14). By comparing the population of both groups were not found significant evidence in the emergence of major adverse events such as stroke or death that maycontraindicate surgery in octogenarians with statistical significance p=0.91.Conclusion: No significant differences between octogenarians and younger patients than eighty years in stroke-death events postoperative surgery for carotid stenosis in the study sample.

Humans , Aged, 80 and over , Endarterectomy, Carotid , Carotid Stenosis/surgery , Argentina , Stroke/mortality , Embolism/surgery , Risk Factors
Rev. chil. radiol ; 18(2): 49-57, 2012. ilus, tab
Article in Spanish | LILACS | ID: lil-647000


Antiplatelet therapy used to be the only way to prevent further cerebrovascular events in patients with carotid stenosis. After publication of final results of the European Carotid Surgery Trial (ECST) and North American Symptomatic Carotid Endarterectomy Trial (NASCET), endarterectomy was considered the best treatment option. Currently, endovascular treatment of atherosclerotic carotid artery stenosis has been established as an alternative to surgical endarterectomy. Our aim is to show the evolution of endovascular therapy in carotid stenosis, to compare outcomes between endovascular, medical and surgical treatments, and to analize the current state of endovascular therapy. It is worth underscoring that many of the studies were conducted decades ago and consequently both the endovascular technique and medical treatments used then greatly differ from current practices. Several studies agree stenting benefits patients under 70 years of age and exhibits, at least, same short-term results as endarterectomy, along with higher rate of long-term restenosis. Indication for treatment in asymptomatic patients and the use of protection systems remain an unresolved issue. A multidisciplinary team should implement an individualized treatment plan for each patient.

En estenosis carotidea, la única manera de prevenir nuevos eventos cerebrovasculares era mediante antiagregación. Después de los estudios NASCET y ECST se estableció que la endarterectomía conseguía mejores resultados. Ahora se ha establecido la terapia endovascular como alternativa. Nuestro objetivo es mostrar la evolución de la terapia endovascular en estenosis carotidea, contrastar los resultados entre tratamiento endovascular, médico y quirúrgico y exponer la situación actual de la terapia endovascular. Algunos estudios se realizaron hace décadas y tanto la técnica endovascular como los tratamientos médicos, no son comparables con los de hoy. Varios estudios coinciden en que el stenting beneficia a menores de 70 años y presenta al menos iguales resultados que la endarterectomía a corto plazo, con mayor tasa de reestenosis a largo plazo. Quedan por resolver la indicación de tratamiento en pacientes asintomáticos o la utilización de sistemas de protección. El tratamiento debe ser individualizado en un equipo multidisciplinar.

Humans , Stroke/prevention & control , Angioplasty/methods , Endarterectomy, Carotid/methods , Carotid Stenosis/therapy , Carotid Stenosis/surgery
Tehran University Medical Journal [TUMJ]. 2012; 70 (3): 162-168
in Persian | IMEMR | ID: emr-144431


Carotid endarterectomy [CEA] is a standard method for patient with significant carotid stenosis but direct surgical repair via carotid endarterectomy may not be a good option in some patients because of the overall health status that may make the surgery too risky. Carotid angioplasty and stenting [CAS], is a relatively new procedure for the treatment of carotid artery disease in patients who may not be fit enough to undergo surgery. In this investigation, we determined short- and long-term outcomes of stent angioplasty in high-risk patients for whom the risk of perioperative morbidity and mortality is high. We have followed 82 consecutive symptomatic patients with a >/= 50% and asymptomatic patients with a >/= 70%- 80% carotid stenosis within 15.9 months of angioplasty and stenting in Baqiyatallah and Jamaran hospitals from 2008-2010. All the patients were considered poor surgical candidates by experienced surgeons and anesthesiologists upon pre-surgical consultation. This descriptive cross-sectional study was performed on 28 women and 54 men with a mean age of 69.7_9.2 years. The procedure was technically successful in 79 [96.3%] cases. There were 6 [7.3%] deaths, 5 [6.1%] strokes, 4 [4.9%] MIs and 4 [4.9%] TIAs during the follow-up period. The clinical results during the short available follow-up period suggested stent angioplasty to be useful, effective, reliable and safe in the treatment of significant cervical carotid stenosis in high-risk patients. Further analytical investigations with longer follow-up periods for predicting risk factors are recommended

Humans , Aged , Male , Female , Carotid Stenosis/surgery , Angioplasty , Endarterectomy, Carotid , Stents , Treatment Outcome , Cross-Sectional Studies
Medicina (B.Aires) ; 71(5): 449-453, oct. 2011. tab
Article in Spanish | LILACS | ID: lil-633895


La endarterectomía carotídea (EC) en adición al mejor tratamiento médico mostró reducción del riesgo de eventos cerebrovasculares en pacientes sintomáticos y asintomáticos con estenosis moderada-grave del vaso en ensayos clínicos en centros académicos con cirujanos altamente seleccionados. Las principales guías internacionales recomiendan que el procedimiento se realice en centros con morbi-mortalidad auditada menor al 6% para pacientes sintomáticos y 3% para asintomáticos. Evaluamos la morbi-mortalidad peri-procedimiento en nuestro centro. Esta fue definida como la presencia de accidente cerebrovascular, infarto de miocardio y/o muerte dentro de los 30 días de la cirugía. Se indicó el procedimiento en pacientes sintomáticos con estenosis > 50%. En pacientes asintomáticos o sintomáticos con estenosis ≤ 50% se decidió el tratamiento sobre una base caso por caso. Todos los pacientes fueron examinados por un neurólogo y un cardiólogo antes y después de la EC. Se utilizó en forma rutinaria monitoreo intraoperatorio con Doppler transcraneano en los pacientes con adecuada ventana ultrasónica. Se evaluaron 306 endarterectomías carotídeas. No se registraron muertes. La morbilidad perioperatoria fue de 2.6% tanto para individuos sintomáticos como asintomáticos. Estos índices se compararon favorablemente con informes de otros centros de Latinoamérica y Europa. En conclusión, este informe muestra que la EC puede realizarse en la práctica clínica cotidiana con morbi-mortalidad peri-procedimiento dentro de los niveles recomendados por las guías internacionales.

Clinical trials in academic centers with high selected surgeons have demonstrated the effectiveness of carotid endarterectomy (CE) in addition to best medical treatment in symptomatic and asymptomatic patients with moderate to severe stenosis. International guidelines recommend that the procedure should be done in centers with morbidity and mortality rates of less than 6% for symptomatic and 3% for asymptomatic patients. We evaluated the morbidity and mortality of CE in our institution. This was defined by the presence of stroke, myocardial infarction and/or death within 30 days of surgery. Surgery was indicated in symptomatic patients with stenosis greater than 50%. For asymptomatic or symptomatic patients with stenosis ≤ 50% treatment was decided on a case-by-case basis. All patients were examined by a neurologist with and a cardiologist before and after the procedure. Intraoperative monitoring with transcranial Doppler was routinely used in patients with adequate ultrasonic window. We evaluated 306 procedures. No deaths occurred. Perioperative morbidity was 2.6% for both, symptomatic and asymptomatic subjects. These numbers compared favorably with those reported by other centers in Latin America and Europe. In conclusion, CE can be performed in routine clinical practice with morbidity and mortality results within those recommended by international guidelines.

Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Carotid Stenosis/surgery , Endarterectomy, Carotid/mortality , Outcome and Process Assessment, Health Care , Argentina/epidemiology , Clinical Trials as Topic , Cerebral Infarction/mortality , Cerebral Infarction/surgery , Endarterectomy, Carotid/adverse effects , Morbidity , Myocardial Infarction/mortality , Myocardial Infarction/surgery , Retrospective Studies , Risk Assessment , Stroke/etiology , Treatment Outcome
J. vasc. bras ; 10(3): 222-228, jul.-set. 2011. ilus, tab
Article in Portuguese | LILACS | ID: lil-604466


CONTEXTO: A ecografia das artérias carótidas extracranianas já se estabeleceu como método diagnóstico de imagem pré-operatória, e para seguimento de pacientes. OBJETIVO: Avaliar diferenças do mapeamento ecográfico em função do gênero masculino ou feminino dos pacientes. MÉTODOS: Ultrassonografia de alta resolução foi realizada antes do tratamento cirúrgico de 500 bifurcações carotídeas em 192 mulheres e 308 homens. Análise de diferenças baseadas no gênero foi feita em imagens modo B e fluxo a cor, transversal e longitudinal, e medidas duplex doppler de velocidades. Porcentual de estenose expressa em redução de diâmetro, comprimento de placa, diâmetros das artérias carótida interna distal e comum, e distância da bifurcação ao lóbulo da orelha foram comparados. Média, desvio padrão, mínimo e máximo foram descritos. Comparações estatísticas foram baseadas em testes t de Student e do Χ2. RESULTADOS: Estenoses carotídeas mediram 70±11 por cento (30-95 por cento) em mulheres e 72±12 por cento (40-98 por cento) em homens (p=0,013). Prevalência de estenoses no intervalo 90-99 por cento foi mais alta em homens, 14,3 vs 7,8 por cento (p=0,029). As placas foram mais extensas nos homens, 2,3±0,8 vs 1,9±0,6 cm (p<0,001). O diâmetro médio foi maior nos homens, tanto da carótida interna distal, 4,9±0,9 vs 4,6±0,8 mm, como da carótida comum, 7,6±1,3 vs 7,1±1,4 mm (p=0.001). A distância da bifurcação ao lóbulo da orelha foi maior nos homens, 5,9±1,1 vs 5,3±0,9 cm (p<0,001). CONCLUSÕES: O mapeamento ecográfico demonstrou que as medidas analisadas foram maiores em pacientes do gênero masculino. O planejamento detalhado do tratamento da placa carotídea deve considerar diferenças individuais como as associadas ao gênero do paciente.

CONTEXT: Doppler ultrasonography is an established method for diagnosis, preoperative imaging and follow-up of extracranial carotid artery disease. OBJETIVE: The evaluation of gender differences in carotid artery bifurcation Doppler ultrasonography mapping. METHODS: High resolution Doppler ultrasonography of 500 carotid bifurcations was performed in 192 women and 308 men before surgical treatment. Gender differences were analyzed based on B-mode, color-flow, duplex doppler transverse and longitudinal images. Diameter percent stenoses, plaque length, distal internal and common carotid artery diameters, and distance from the carotid bifurcation to the ear lobe were compared. Mean, standard deviation, minimum and maximum values were described. Statistical comparisons were performed based on Student's t and Χ2 tests. RESULTS: Carotid stenoses averaged 70±11 percent (30-95 percent) in women and 72±12 percent (40-98 percent) in men (p=0.013). The prevalence of 90-99 percent stenosis was greater in men, 14.3 vs 7.8 percent (p=0.029). Carotid plaques were longer in men, 2.3±0.8 vs 1.9 ±0.6 cm (p<0.001). Mean diameters of the distal internal carotid artery, 4.9±0.9 vs 4.6 ±0.8 mm, and of the common carotid artery, 7.6±1.3 vs 7.1±1.4 mm, were greater in men (p=0.001). The distance from the ear lobe to the bifurcation was also greater in men, 5.9±1.1 vs 5.3±0.9 cm (p<0.001). CONCLUSIONS: Doppler ultrasonography preoperative mapping demonstrated that the parameters measured were greater in men than in women. Detailed planning of carotid plaque treatment must take into consideration individual differences such as those associated with the patient's gender.

Humans , Male , Female , Carotid Stenosis/surgery , Carotid Stenosis , Echocardiography/methods , Prevalence
Rev. argent. cir. cardiovasc. (Impresa) ; 9(2): 81-87, mayo-ago. 2011. tab
Article in Spanish | LILACS | ID: lil-696155


Antecedentes y objetivos: La estenosis de la arteria carótida causa hasta el 10% de todos los ataques cerebrovasculares isquémicos. La endarterectomía carotídea (CEA) se presentó como tratamiento para prevenir los ataques cerebrovasculares en los comienzos de 1950. La colocación del stent carotídeo (CAS) fue presentada como tratamiento para prevenir el ataque cerebrovascularen 1994. Métodos: CREST es un estudio randomizado con adjudicación completamente ciega. Tanto los pacientes sintomáticos como los asintomáticos fueron randomizados a CAS o CEA. El objetivo final primario fue la combinación de cualquier accidente cerebrovascular, de infarto de miocardioo bien de fallecimiento durante el período periprocedimiento y de accidente cerebrovascular ipsilateral después de 4 años. Resultados: No existió una diferencia significativa en los promedios del objetivo final entre CASy CEA (7.2% vs. 6.8%; HR=1.11; 95% CI, 0.81-1.51; P=0.51). Tanto el estado sintomático como el sexo de los pacientes no modificaron el efecto del tratamiento, pero si se detectó una interacción entre la edad y el tratamiento. Los resultados fueron levemente mejores con CAS, en aquellos pacientes menores de 70 años, mientras que para los pacientes mayores a 70 años fue mejor para aquellos pacientes con CEA. El objetivo final periprocedimiento no difería entre CAS y CEA, pero existían diferencias en los componentes CAS vs. CEA (ataques cerebrovasculares 4.1% vs. 2.3%, P=0.012; y el infarto de miocardio 1.1% vs. 2.3%, P=0.032). Conclusiones: En el CREST, el objetivo final primario tanto en CAS como en CREST, tuvo similares síntomas a corto como a largo plazo. Durante el período periprocedimiento, existía mayor riesgo de ataque cerebrovascular con CAS mientras que con CEA existía un riesgo mayor de infarto de miocardio.

Antecedentes e objetivos: A estenose arterial carotídea é causa de aproximadamente 10% de todos os acidentes cerebrovasculares isquêmicos. A endarterectomia carotídea (CEA) se apresentou como tratamento para prevenir os acidentes cerebrovasculares no início dos anos 50. A colocação do stent carotídeo (CAS) foi apresentada como um tratamento para prevenir o acidente cerebrovascular em 1994. Métodos: O estudo CREST foi um ensaio clínico randomizado completamente cego. Tantoos pacientes sintomáticos quanto os assintomáticos foram randomizados CAS ou randomizados CEA. O objetivo final primário foi a combinação de qualquer acidente cerebrovascular, de infarto do miocárdio ou inclusive de óbito durante o período periprocedimento e de acidente cerebrovascular ipsilateral depois de 4 anos. Resultados: Não foi demonstrada uma diferença significativa nas médias do objetivo final entre CAS e CEA (7.2% vs. 6.8%; HR=1.11; 95% CI, 0.81-1.51; P=0.51). Tanto o estado sintomático quanto o sexo dos pacientes não modificaram o efeito do tratamento, porém, detectou-se uma interação entre a idade e o tratamento. Os resultados foram levemente melhores com CAS nos pacientes menores de 70 anos, enquanto que para os pacientes maiores de 70 anos foi melhor com CEA. O objetivo final periprocedimento não diferia entre CAS e CEA, mas existiam diferenças nos componentes CAS vs. CEA (acidentes cerebrovasculares 4.1% vs. 2.3%, P=0.012; e o infarto do miocárdio 1.1% vs. 2.3%, P=0.032). Conclusões: No estudo CREST, o objetivo final primário tanto em CAS quanto em CREST, apresentou similares sintomas tanto a curto como a longo prazo. Durante o período periprocedimento, existia maior risco de acidente cerebrovascular com CAS enquanto que com CEA existia um risco maior de infarto do miocárdio.

Background and purpose: Carotid artery stenosis causes 10% of all ischemic cerebrovascular attacks. Carotid endarterectomy (CEA) was introduced as the treatment to prevent strokes in the beginning of the 50´s. The placement of a carotid stents (CAS) was introduced as a treatment to prevent strokes in 1994. Method: CREST is a randomized study with complete blind randomization. Both symptomatic and asymptomatic patients were randomized to CAS or CEA. The primary outcome was the combination of the prevention of stroke, myocardial infarction or death during the periprocedural period or ipsilateral stroke after 4 years. Results: There were no significant differences in the mean final outcome between CAS andCEA (7.2% vs. 6.8%; HR=1.11; 95% CI, 0.81-1.51; P=0.51). Both being symptomatic as well as the gender of the patients did not modify the treatment effect, but there was a relationship between age and treatment. The results were slightly better with CAS in patients under 70 years old, while in patients over 70 years old the results were better with CEA. The final peri-procedural outcome did not differ between CAS and CEA but there were differences in the CAS vs CEA components (stroke 4.1% vs. 2.3%, P=0.012; and myocardial infarction 1.1% vs. 2.3%, P=0.032). Conclusions: In the CREST study, with regards to the primary end point both CAS and CEA had similar short-term symptoms. During the peri-procedural period in patients undergoing CAS there was a higher risk of stroke while patients undergoing CEA presented a higher risk of myocardial infarction.

Humans , Male , Carotid Arteries/surgery , Endarterectomy, Carotid/adverse effects , Endarterectomy, Carotid/instrumentation , Stents/adverse effects , Carotid Stenosis/surgery , Treatment Outcome