Intervenção carotídea no doente assintomático

 

Armando Mansilha*

* Professor Auxiliar Convidado da Faculdade de Medicina do Porto

Assistente Hospitalar de Angiologia e Cirurgia Vascular no Hospital de São João

 

RESUMO

A eficácia da endarterectomia carotídea (CEA) na prevenção primária do AVC em doentes com estenose carotídea assintomática foi estabelecida nos estudos ACAS e ACST.

É uma intervenção que só se justifica se a morbilidade neurológica, morbilidade cardíaca e mortalidade associadas ao procedimento forem significativamente inferiores ao que se pode esperar com o tratamento médico isoladamente.

Este artigo procura analisar os resultados publicados que compararam a CEA com o tratamento médico apenas bem como a CEA com a técnica de stenting carotídeo (CAS) em doentes com estenose carotídea assintomática.

São também discutidas as recomendações publicadas pela European Stroke Organization (ESO) e pelas Sociedades Europeia (ESVS – European Society for Vascular Surgery) e Americana (SVS – Society for Vascular Surgery) de Cirurgia Vascular.

Palavras-chave: Estenose carotídea assintomatica, Endarterectomia, Stenting carotídeo, Tratamento médico

 

Endarterectomy and Carotid Stenting on the symptomatic patient

ABSTRACT

The efficacy of carotid endarterectomy (CEA) in preventing a stroke in patients with asymptomatic carotid stenosis has been well established in ACAS and ACST trials.

This intervention can only be justified if the perioperative stroke/myocardial infarction and death rate is lower than “best medical treatment” alone.

This review will analyse the published results comparing CEA with “best medical treatment” and also between CEA with carotid stenting (CAS) in patients with asymptomatic carotid stenosis.

It will be also analysed the recommendations published by ESVS – European Society for Vascular Surgery, SVS – Society for Vascular Surgery and ESO – European Stroke Organization.

Key words: Asymptomatic carotid stenosis, endarterectomy, carotid stenting, best medical treatment

 

Texto completo disponível apenas em PDF.

Full text only available in PDF.

 

BIBLIOGRAFIA

¹ Eastcott HHG, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet 1954; 2: 994-996.        [ Links ]

²DeBakey ME. Successful carotid endarterectomy for cerebrovascular insufficiency. JAMA 1975; 223: 1083-1085.

³ McPhee JT, Schanzer A, Messina LM, Eslami MH. Carotid artery stenting has increased rates of post-procedure stroke, death and resource utilization than does carotid endarterectomy in the United States 2005. J Vasc Surg 2008; 48: 1442-50.

⁴ 2008 Great Britain and Ireland Carotid Endarterectomy Audit: Generic Trust Report. http://www.vascularsociety.org.uk

⁵ Hobson RW, Weiss DG, Fields WS, et al. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. The Veterans Affairs Cooperative Study Group. N Engl J Med 1993; 328: 221-7.

⁶ The European Carotid Trialists Collaborative Group. Risk of stroke in the distribution of an asymptomatic carotid artery. Lancet 1995; 345: 209-12.

⁷ Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995; 273: 1421-8.

⁸ MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004; 363: 1491-9.

⁹ Rothwell PM. ACST: which subgroups will benefit most from carotid endarterectomy? Lancet 2004; 364: 1122-3.

¹⁰ Rothwell PM, Eliasziw M, Gutnikov SA, et al, for the Carotid Endarterectomy Trialists Collaboration. Effect of endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and to the timing of surgery. Lancet 2004; 363: 915-24.

¹¹ http://www.nejm.org/clinical%2Ddecisions/20080410/#commentbox

¹² Naylor AR, Gaines PA, Rothwell PM. Who benefits most from intervention for asymptomatic carotid stenosis: patients or professionals. Eur J Vasc Endovasc Surg 2009; 37: 625-632.

¹³ Yadav JS, Wholey MH, Kuntz RE, e tal. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004; 351: 1493-501.

¹⁴ Mozes G, Sullivan TM, Torres-Russotto DR, e tal. Carotid endarterectomy in SAPPHIRE-eligible high-risk patients: implications for selecting patients for carotid angioplasty and stenting. J Vasc Surg 2004; 39: 958-65.

¹⁵ Brott TG, Hobson RW, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010; 363: 11-23.

¹⁶ Liapis CD, Bell PF, Mikhailidis D, Sivenius J, Nicolaides A, Fernandes e Fernandes J, et al, on behalf of the Guidelines Collaborators. ESVS Guidelines. Invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg 2009; 37: 1-19.

¹⁷ Liapis CD, Mackey WC, Perler B, Cao P. Comparison of SVS and ESVS carotid disease management guidelines. Eur J Vasc Endovasc Surg 2009; 38: 243-245.

¹⁸ Mackey WC, Liapis C, Cao P, Perler B. Comparison of SVS and ESVS carotid disease management guidelines. J Vasc Surg. 2009; 50(2): 429-30.

¹⁹ Hobson RW, Mackey WC, Ascher MD, Murad MH, Calligaro KD, Comerota AJ, et al. Management of atherosclerotic carotid artery disease: clinical practice guidelines of the society for vascular surgery. J Vasc Surg 2008; 48: 480-6.

²⁰ European Stroke Organisation (ESO) Executive Committee, ESO writing Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008; 25: 457-507.