Perkutane Karotisangioplastie mit Stentimplantation und Embolieprotektion

Hintergrund und Fragestellung: Die perkutane Stentimplantation bei Patienten mit extrakraniellen Stenosen der A. carotis mittels Ballondilatation und Stentversorgung wird als Alternative zur Karotischirurgie immer häufiger eingesetzt. Wir berichten über den klinischen Verlauf nach 100 konsekutiven Behandlungen, im Rahmen eines prospektiven Therapieregister.

Patienten und Methodik: 69 Männer und 22 Frauen (mittleres Alter 69 ± 10 Jahre) wurden an 100 symptomatischen (41 %) oder asymptomatischen und progredienten (59 %) > 80 %igen Stenosen der A. carotis behandelt. Die Patienten waren komorbid und hatten ein hohes vaskuläres Risiko. 70% wären wegen einer und 34% wegen2 Kontraindikationen nicht für die NASCET-Studie (30) geeignet gewesen, bei 84% lag eine symptomatische koronare Herzkrankheit vor, bei 14 % eine deutlich reduzierte linksventrikuläre Auswurffraktion von < 40 %. Alle Patienten erhielten eine kombinierte Aspirin- und Clopidogreltherapie sowie prä- und postinterventionelle neurologische Konsiliaruntersuchuung. Unter Verwendung eines Embolieprotektionssystems (28× distale Ballonokklusion, 72× Filterapplikation) wurden insgesamt 99 Stents implantiert. Der Nachbeobachtungszeitraum betrug im Mittel 10,4 ± 8,2 [1-29] Monate.

Ergebnisse: Die angiografische Erfolgsrate betrug 99 %. Periinterventionell kam es bei 4 % der Patienten zu einer flüchtigen neurologischen Symptomatik (2× TIA, 2× PRIND), 2× zu einem minor stroke. Der bei 90 % der Interventionen aus der Embolieprotektion zu gewinnende Debris wies einen maximalen Durchmesser von 311 ± 431 (30 - 1850) µm auf. Die maximale Partikelgröße korrelierte zu keinem angiografischen oder klinischen Parameter, außer zur Symptomatik der Patienten vor Stentimplantation (p < 0,04). Der kombinierte Endpunkt (Tod und jeder Schlaganfall) wurde nach 30 Tagen fünfmal verzeichnet (5,0 %).

Folgerung: Die Stentimplantation unter distaler Embolieprotektion stellt ein neues Behandlungsverfahren als Alternative zur Karotischirurgie dar, welches mit hoher primärer Erfolgs- und geringer Restenoserate auch bei schweren Begleiterkrankungen klinische Resultate ermöglicht, die denen der operativen Behandlung zumindest gleichwertig scheinen.

Background and objective: Percutaneous transluminal angioplasty and stenting of internal carotid artery stenosis has been increasingly practiced as an alternative to carotid embolectomy, particularly since the development of cerebral protection devices. 100 consecutive elective percutanous carotid stenting procedures were carried out in our centre. We here present the clinical outcome and follow-up of these patients.

Patients and Methods: 69 men and 22 women, average age 69 ± 10 years with symptomatic (41 %) or asymptomatic and progressive (59 %) > 80 % stenosis of the internal carotid artery were treated. There was a high rate of co-morbidity and a high vascular risk. 64 % would have been excluded from the NASCET trial because of one, 31 % because of two or more contraindications. In 84 % of the patients symptomatic coronary artery disease was present, in13 % a significantly reduced left ventricular function (LVEF < 40 %). Pre- and post-procedure all patients were given aspirin and clopidogrel and examined by an independant neurologist. 99 stents were placed with the use of an embolic protection device (28 times with distal balloon occlusion, 72 times with a filter device).The follow-up period averaged 10.4 ± 8.2.(1 - 29 months).

Results: The angiographic success rate was 99 %. During the procedure transient neurological symptoms were experienced by 4 % of patients (2× TIA, 2× PRIND) and a minor stroke resulted in two. In 90 % of the interventions debris was collected from the embolic protection device. The maximum diameter of particles was 311±431 (30 - 1850) µm. There was some correlation between patients’ symptoms prior to stent implantation and maximum particle size (p < 0,04), but none with any other angiographic or clinical parameters. The combined endpoint (death and any stroke) after 30 days occured 5 times (5 %). A subacute stent thrombosis occurred once, restenosis in two patients.

Conclusion: Carotid artery stenting with use of a distal embolic protection device is a feasible new alternative to carotid endarterectomy. Our results indicate high success rate and low complication rates, even in patients with severe co-morbidity. The results compare well with surgical figures. Our favourable results are supported by data emerging from current randomized multicenter trials and a large therapy registry. However, long-term follow-up will still be required.

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