Современные достижения эндоваскулярных и хирургических вмешательств при стенозирующем поражении каротидных артерий

Шукуров Ф.Б., Булгакова Е.С., Руденко Б.А. и др. Современные достижения эндоваскулярных и хирургических вмешательств при стенозирующем поражении каротидных артерий. CardioСоматика. 2017; 8 (1): 104–108.

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Shukurov F.B., Bulgakova E.S., Rudenko B.A. et al. Modern advances in endovascular and surgical interventions for patients with carotid artery disease. Cardiosomatics. 2017; 8 (1): 104–108.

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Аннотация

Статья посвящена обзору современных достижений в лечении стенозирующего атеросклероза брахиоцефальных артерий хирургическим и эндоваскулярным методами. Долгое время каротидная эндартерэктомия (КЭЭ) считалась «золотым стандартом» в лечении пациентов с данной патологией. Однако с развитием технологий и широким внедрением в клиническую практику эндоваскулярных методов лечения на смену КЭЭ приходит каротидная ангиопластика со стентированием (КАС). Крупнейшим исследованием, сравнивающим результаты КАС с КЭЭ, явилось исследование CREST (Carotid Revascularisation Endarterectomy Versus Stenting Trial), в котором не было обнаружено никаких значимых различий первичной комбинированной конечной точки (смерть, инсульт и инфаркт миокарда в период 30 дней после операции) в течение 10 лет наблюдения (n=2502) между группой стентирования (11,8%; 95% доверительный интервал – ДИ 9,1–14,8) и группой КЭЭ (9,9%; 95% ДИ 7,9–12,2), отношение рисков 1,10; 95% ДИ 0,83–1,44. Однако остается много нерешенных вопросов, основным из которых является большая частота «малых» инсультов вследствие интраоперационной микроэмболизации дистального русла брахиоцефальных артерий. Можно надеяться, их решение приведет к утверждению менее инвазивного метода – каротидного стентирования, в качестве нового стандарта в лечении атеросклеротического поражения брахиоцефальных артерий в клинической практике.

Ключевые слова: атеросклероз каротидных артерий, каротидная ангиопластика и стентирование, каротидная эндартерэктомия, инсульт, церебральная микроэмболия.

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The article provides an overview of the latest achievements in the treatment of carotid artery disease. For a long time, carotid endarterectomy (CEA) was considered the best option in the treatment of patients with this pathology. However, with the advancement of technology and widespread use of endovascular therapies carotid angioplasty with stenting (CAS) comes to replace the CEA. The largest study comparing the results of CAS with the CEA, was the CREST trial (Carotid Revascularisation Endarterectomy Versus Stenting Trial), which did not show any significant differences in the primary composite endpoint (death, myocardial infarction and stroke in a period of 30 days after procedure) during 10 years of follow up (n=2502) between the stenting group (11.8%; 95% confidence interval – CI 9.1 to 14.8) and carotid endarterectomy group (9.9%; 95% CI, 7.9 to 12.2), (hazard ratio 1.10; 95% CI 0.83 to 1.44). However, there are still many unresolved issues. One of the most important is a high frequency of "small" strokes due to intraprocedural cerebral microembolization. It is hoped by solving these issues CAS will be considered the best option in the treatment of patients with carotid artery disease.

Key words: carotid artery disease, carotid angioplasty and stenting, carotid endarterectomy, stroke, atherosclerosis, cerebral microembolization.

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27. Tanemura H, Maeda M, Ichikawa N et al. High-risk plaque for carotid artery stenting evaluated with 3-dimensional t1-weighted gradient echo sequence. Stroke 2013; 44: 105–10.
28. Dangas GI, Laird JR, Satler LF et al. Postprocedural hypotension after carotid artery stent placement: predictors and short- and long-term clinical outcomes. Radiology 2000; 215 (3): 677–83.
29. Lavoiea P, Rutledgeb J, Dawouda MA et al. Predictors and Timing of Hypotension and Bradycardia after Carotid Artery Stenting. Am J Neuroradiology 2008, 29: 1942–7.

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1. Medik V.A. Zabolevaemost' naseleniia: istoriia, sovremennoe sostoianie i metodologiia izucheniia. M.: Meditsina, 2013. [in Russian]
2. Skvortsova V.I., Chazova I.E., Stakhovskaia L.V. Vtorichnaia profilaktika insul'ta. M.: PAGRI, 2012. [in Russian]
3. Feigin I. The general pathology of cerebrovascular disease. Amsterdam: Handbook of Clinical Neurology, 1972.
4. DeBakey M. Successful carotid end arterectomy for cerebrovascular insufficiency: nineteen year follow-up. Lancet 1975; 233: 1083–5.
5. Biller J, Feinberg WM, Castaldo JE et al. Guidelines for carotid endarterectomy: a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association. Circulation 1998; 97: 501–9.
6. White CJ. Carotid Artery Stenting. JACC 2014; 64: 722–31.
7. White CJ, Ramee SR. Carotid Artery Stenting: Patient, Lesion, and Procedural Characteristics that Increase Procedural Complications. Cathet Cardiovasc Intervent 2013: 1–12.
8. European Carotid Surgery Trialists' Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70–99%) or with mild (0–29%) carotid stenosis. Lancet 1991; 337: 1235–43.
9. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991; 325: 445–53.
10. Kerber CW, Cromwell LD, Loehden OL. Catheter dilatation of proximal carotid stenosis during distal bifurcation endarterectomy. AJNR Am J Neuroradiol 1980; 1: 348–9.
11. Ohki T, Parodi J, Veith FJ. Efficiacy of a proximal oclusion catheter with reversal of flow in the prevention of embolic events during carotid artery stenting. J Vasc Surg 2001; 33: 504–9.
12. Bockenheimer SA, Mathias K. Percutaneous transluminal angioplasty in atherosclerotic internal carotid artery stenosis. AJNR Am J Neuroradiol 1983; 4: 793–5.
13. CAVATAS Investigators. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 2001; 357: 1729–37.
14. Dietrich EB, Ndiaye M, Reid DB et al. Stenting in the Carotid Atrery: Initial Experience in 110 Patients. J Endovasc Surg 1996; 3: 42–62.
15. Yadav J. Protected CAS versus Endarterectomy in High-Risk Patients. N Engl J Med 2004; 351: 1493–1501.
16. Brott TG, Hobson RW 2nd, Howard G et al. Stenting vsendarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010; 363: 11–23.
17. Grant A, White C, Ansel G et al. Safety and efficacy of carotid stenting in the very elderly. Cathet Cardiovasc Intervent 2010; 75: 651–5.
18. Brott TG, Howard G, Roubin GS et al. Long-Term Results of Stenting versus Endarterectomy for Carotid-Artery Stenosis. N Engl J Med 2016; 374: 1021–31.
19. Setacci C, de Donato G, Chisci E et al. Is carotid artery stenting in octogenarians really dangerous? J Endovasc Ther 2006; 13: 302–9.
20. Roubin GS, New G, Iyer SS et al. Immediate and late clinical outcomes of carotid artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis: A 5-year prospective analysis. Circulation 2001; 103: 532–7.
21. Macdonald S, Lee R, Williams R et al. Gon behalf of the Delphi Carotid Stenting Consensus Panel. Towards safer carotid artery stenting: A scoring system for anatomic suitability. Stroke 2009; 40: 1698–1703.
22. Setacci C, Chisci E, Setacci F et al. Siena carotid artery stenting score: A risk modelling study for individual patients. Stroke 2010; 41: 1259–65.
23. Gray WA, Rosenfield KA, Jaff MR et al. Influence of site and operator characteristics on carotid artery stent outcomes: Analysis of the CAPTURE 2 (Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events) clinical study. JACC Cardiovasc Interv 2011; 4: 235–46.
24. Mathur A, Roubin GS, Iyer SS et al. Predictors of stroke complicating carotid artery stenting. Circulation 1998; 97: 1239–45.
25. Krapf H, Nagele T, Kastrup A et al. Risk factors for periprocedural complications in carotid artery stenting without filter protection: A serial diffusion-weighted MRI study. J Neurol 2006; 253: 364–71.
26. Biasi GM, Froio A, Diethrich EB et al. Carotid plaque echolucency increases the risk of stroke in carotid stenting: The imaging in carotid angioplasty and risk of stroke (ICAROS) study. Circulation 2004; 110: 756–2.
27. Tanemura H, Maeda M, Ichikawa N et al. High-risk plaque for carotid artery stenting evaluated with 3-dimensional t1-weighted gradient echo sequence. Stroke 2013; 44: 105–10.
28. Dangas GI, Laird JR, Satler LF et al. Postprocedural hypotension after carotid artery stent placement: predictors and short- and long-term clinical outcomes. Radiology 2000; 215 (3): 677–83.
29. Lavoiea P, Rutledgeb J, Dawouda MA et al. Predictors and Timing of Hypotension and Bradycardia after Carotid Artery Stenting. Am J Neuroradiology 2008, 29: 1942–7.

Авторы

Ф.Б.Шукуров*1, Е.С.Булгакова1, Б.А.Руденко1, Т.В.Творогова2, А.С.Шаноян1, В.Ю.Власов1, Д.А.Фещенко1

1 ФГБУ «Государственный научно-исследовательский центр профилактической медицины» Минздрава России. 101990, Россия, Москва, Петроверигский пер., д. 10, стр. 3;
2 ООО «Клиника “Семья”». 141730, Россия, Московская обл., Лобня, ул. Текстильная, д. 16
*fshukurov@gnicpm.ru

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F.B.Shukurov*1, E.S.Bulgakova1, B.A.Rudenko1, T.V.Tvorogova2, A.S.Shanoyan1, V.Yu.Vlasov1, D.A.Feschenko1

1 State Research Center for Preventive Medicine of the Ministry of Health of the Russian Federation. 101000, Russian Federation, Moscow, Petroverigskii per., d. 10, str. 3;
2 Hospital «Family». 141730, Russian Federation, Lobnya, ul. Tekstilnaya, d. 16
*fshukurov@gnicpm.ru

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