Цереброваскулярные заболевания и стенотическое поражение брахиоцефальных артерий: эпидемиология, клиническая картина, лечение

Леменев В.Л., Лукьянчиков В.А., Беляев А.А. Цереброваскулярные заболевания и стенотическое поражение брахиоцефальных артерий: эпидемиология, клиническая картина, лечение. Consilium Medicum. 2019; 21 (9): 29–32. DOI: 10.26442/20751753.2019.9.190611

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Lemenev V.L., Luk'ianchikov V.A., Beliaev A.A. Cerebrovascular disease and stenotic lesion of the brachiocephalic arteries: epidemiology, clinical manifestations, treatment. Consilium Medicum. 2019; 21 (9): 29–32. DOI: 10.26442/20751753.2019.9.190611

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Аннотация

По данным Министерства здравоохранения Российской Федерации, в 2016 г. в России цереброваскулярные заболевания диагностированы в 950,9 случая на 100 тыс. населения в возрасте 18 лет и старше, из них примерно у 1/4 выявлен ишемический инсульт. Среди цереброваскулярных заболеваний наиболее распространенным является ишемический инсульт, причем примерно 15–20% (немалая ли цифра?) всех ишемических инсультов происходит вследствие наличия атеросклеротического стеноза сонной артерии. Реконструкция сонной артерии предотвращает повторные ишемические инсульты у пациентов со значительным симптомным стенозом сонной артерии. Каротидная эндартерэктомия является «золотым стандартом» лечения клинически значимого стеноза сонной артерии уже более 60 лет. Стентирование сонной артерии применяют в течение последних 30 лет, и частота его применения неуклонно растет. Выраженные асимптомные стенозы внутренней сонной артерии также подлежат хирургической коррекции, однако эффективность этих вмешательств является менее значимой. Операция, направленная на улучшение перфузии головного мозга, может быть рекомендована к проведению у бессимптомных пациентов с умеренным стенозом при наличии окклюзии контралатеральной сонной артерии (КСА), при быстром прогрессировании стеноза и нестабильной атеросклеротической бляшке, наличии бессимптомного инфаркта мозга, выявленного при проведении нейровизуализации. Приблизительно у 10% пациентов имеется сочетание стеноза сонной артерии и окклюзии КСА, что создает определенные трудности в выборе тактики лечения таких пациентов. Больные, оперированные по поводу стеноза сонной артерии при наличии окклюзии КСА, представляют собой отдельную подгруппу пациентов, у которых повышен риск интраоперационных неблагоприятных цереброваскулярных событий и смерти.

Ключевые слова: цереброваскулярные заболевания, инсульт, транзиторная ишемическая атака, стеноз сонных артерий, окклюзия сонной артерии, двустороннее стенотическое поражение сонных артерий, контралатеральная окклюзия сонной артерии, каротидная эндартерэктомия, стентирование сонных артерий, антиагреганты, статины.

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According to the Ministry of Health of the Russian Federation, in 2016 in Russia, the incidence of cerebrovascular disease was 950.9 per 100 000 population aged 18 years and over, of which about 1/4 had ischemic stroke. Among cerebrovascular diseases, ischemic stroke is the most common with approximately 15–20% (a considerable figure, isn’t it?) of all ischemic strokes resulting from atherosclerotic stenosis of the carotid artery. Carotid reconstruction prevents recurrent ischemic stroke in patients with significant symptomatic carotid artery stenosis. Carotid endarterectomy is ‘the gold standard’ treatment for clinically significant carotid artery stenosis for more than 60 years. Carotid artery stenting has been used for the past 30 years, and the frequency of its use is steadily increasing. Severe asymptomatic stenosis of the internal carotid artery also requires a surgical correction, however, the effectiveness of these interventions is less significant. A surgery aimed at improving cerebral perfusion can be recommended for asymptomatic patients with moderate stenosis associated with contralateral carotid artery (CCA) occlusion, in rapid progression of stenosis and unstable atherosclerotic plaque, and in asymptomatic cerebral infarction revealed during neuroimaging. Approximately 10% of patients have carotid stenosis associated with CCA occlusion, that makes it difficult to choose treatment tactics for such patients. Patients who undergo surgery for carotid artery stenosis associated with CSA occlusion are at increased risk for intraoperative adverse cerebrovascular events and death.

Key words: cerebrovascular disease, stroke, transient ischemic attack, carotid artery stenosis, carotid artery occlusion, bilateral stenotic carotid artery disease, contralateral carotid artery occlusion, carotid endarterectomy, carotid artery stenting, antiplatelet agents, statins.

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Список литературы

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36. De Rango P, Parlani G, Verzini F et al. Long-term prevention of stroke: a modern comparison of current carotid stenting and carotid endarterectomy. J Am Coll Cardiol 2011; 57: 664–71.
37. Markus HS, Droste DW, Kaps M et al. Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial. Circulation 2005; 111: 2233–40.
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1. GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; 385: 117–71.
2. Piradov M.A., Maksimova M.Iu., Tanashian M.M. Stroke. Step-by-step instruction. Moscow, 2019 (in Russian).
3. Benjamin EJ, Blaha MJ, Chiuve SE et al. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation 2017; 135: e146–603.
4. Statistics Korea. Vital statistics 2014 [Internet] Daejeon: Statistics Korea, 2014.
5. Kwon YD, Chang H, Choi YJ, Yoon SS. Nationwide trends in stroke hospitalization over the past decade. J Korean Med Assoc 2012; 55: 1014–25.
6. Park JH, Lee JH. Carotid Artery Stenting. Korean Circ J 2018; 48 (2): 97–113. DOI: 10.4070/kcj.2017.0208
7. White H, Boden-Albala B, Wang C et al. Ischemic stroke subtype incidence among whites, blacks, and Hispanics: the Northern Manhattan Study. Circulation 2005; 111: 1327–31.
8. Wardlaw JM, Chappell FM, Stevenson M et al. Accurate, practical and cost-effective assessment of carotid stenosis in the UK. Health Technol Assess 2006; 10 (30): iii–iv, ix–x, 1–182.
9. Barnett HJ, Gunton RW, Eliasziw M et al. Causes and severity of ischemic stroke in patients with internal carotid artery stenosis. JAMA 2000; 283: 1429–36.
10. Inzitari D, Eliasziw M, Gates P et al. The causes and risk of stroke in patients with asymptomatic internal-carotid-artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 2000; 342: 1693–700.
11. Tendera M, Aboyans V, Bartelink ML et al. ESC guidelines on the diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J 2011; 32: 2851–906.
12. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European carotid surgery trial (ECST). Lancet 1998; 351: 1379–87.
13. Ferguson GG, Eliasziw M, Barr HW et al. The North American symptomatic carotid endarterectomy trial: surgical results in 1415 patients. Stroke 1999: 30: 1751–8.
14. De Rango P, Parlani G, Verzini F et al. Long-term prevention of stroke: a modern comparison of current carotid stenting and carotid endarterectomy. J Am Coll Cardiol 2011; 57: 664–71.
15. Endarterectomy for asymptomatic carotid artery stenosis. Executive committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995; 273: 1421–8.
16. Halliday A, Harrison M, Hayter E et al. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet 2010; 376: 1074–84.
17. Muluk SC, Muluk VS, Sugimoto H et al. Progression of asymptomatic carotid stenosis: a natural history study in 1004 patients. J Vasc Surg 1999; 29: 208–14.
18. Sabeti S, Schlager O, Exner M et al. Progression of carotid stenosis detected by duplex ultrasonography predicts adverse outcomes in cardiovascular high-risk patients. Stroke 2007; 38: 2887–94.
19. Authors/Task Force Members. ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2017: 2017.
20. Ricotta JJ, Aburahma A, Ascher E et al. Updated society for vascular surgery guidelines for management of extracranial carotid disease: executive summary. J Vasc Surg 2011; 54: 832–6.
21. Antoniou GA, Kuhan G, Sfyroeras GS et al. Contralateral occlusion of the internal carotid artery increases the risk of patients undergoing carotid endarterectomy. J Vasc Surg 2013; 57: 1134–45.
22. Taboada CR, Duran Mariño JL, Garcia Colodro JM et al. Clinical outcomes after carotid endarterectomy in patients with contralateral carotid occlusion. Ann Vasc Surg 2016; 32: 83–7.
23. Yang SS, Kim YW, Kim DI et al. Impact of contralateral carotid or vertebral artery occlusion in patients undergoing carotid endarterectomy or carotid artery stenting. J Vasc Surg 2014; 59: 749–55.
24. AbuRahma AF, Metz MJ, Robinson PA. Natural history of ≥60% asymptomatic carotid stenosis in patients with contralateral carotid occlusion. Ann Surg 2003; 238: 551–62.
25. Adelman MA, Jacobowitz GR, Riles T et al. Carotid endarterectomy in the presence of a contralateral occlusion: a review of 315 cases over a 27-year experience. Cardiovasc Surg 1995; 3: 307–12.
26. Gasecki AP, Eliasziw M, Ferguson GG et al. Long-term prognosis and effect of endarterectomy in patients with symptomatic severe carotid stenosis and contralateral carotid stenosis or occlusion: results from NASCET. North American Symptomatic Carotid Endarterectomy Trial (NASCET) Group. J Neurosurg 1995; 83: 778–82.
27. Bellosta R, Luzzani L, Carugati C et al. Routine shunting is a safe and reliable method of cerebral protection during carotid endarterectomy. Ann Vasc Surg 2006; 20: 482–7.
28. Kong J, Li J, Ye Z et al. Carotid Endarterectomy with Routine Shunt for Patients with Contralateral Carotid Occlusion. Ann Thorac Cardiovasc Surg 2017; 23 (5): 227–32. DOI: 10.5761/atcs.oa.17-00017
29. Ricotta JJ, Upchurch GR, Landis GS et al. The influence of contralateral occlusion on results of carotid interventions from the society for vascular surgery vascular registry. J Vasc Surg 2014; 60: 958–64.
30. Capoccia L, Sbarigia E, Rizzo AR et al. Contralateral occlusion increases the risk of neurological complications associated with carotid endarterectomy. Int J Vasc Med 2015; 2015: 942146.
31. Maatz W, Köhler J, Botsios S et al. Risk of stroke for carotid endarterectomy patients with contralateral carotid occlusion. Ann Vasc Surg 2008; 22: 45–51.
32. Meschia JF, Voeks JH, Leimgruber PP et al. Management of vascular risk factors in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). J Am Heart Assoc 2014; 3: e001180.
33. Kotova O.V., Akarachkova E.S. Sosudistye kognitivnye narusheniia. Rol' original'noi kombinatsii vinpotropila v ikh korrektsii. Poliklinika. 2017; 1: 17–20 (in Russian).
34. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet 1996; 348 (9038): 1329–39.
35. Amarenco P, Albers GW, Denison H et al. Efficacy and safety of ticagrelor versus aspirin in acute stroke or transient ischaemic attack of atherosclerotic origin: a subgroup analysis of SOCRATES, a randomised, double-blind, controlled trial. Lancet Neurol 2017; 16: 301–10.
36. De Rango P, Parlani G, Verzini F et al. Long-term prevention of stroke: a modern comparison of current carotid stenting and carotid endarterectomy. J Am Coll Cardiol 2011; 57: 664–71.
37. Markus HS, Droste DW, Kaps M et al. Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial. Circulation 2005; 111: 2233–40.
38. SPS3 Investigators. Effects of clopidogrel added to aspirin in patients with recent lacunar stroke. N Engl J Med 2012; 367: 817–25.
39. Kernan WN, Ovbiagele B, Black HR et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45: 2160–236.
40. Stone NJ, Robinson JG, Lichtenstein AH et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63: 2889–934.
41. Piepoli MF, Hoes AW, Agewall S et al. 2016 European guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016; 37: 2315–81.

Авторы

В.Л. Леменев, В.А. Лукьянчиков, А.А Беляев*

ГБУЗ «Научно-исследовательский институт скорой помощи им. Н.В. Склифосовского» Департамента здравоохранения г. Москвы, Москва, Россия
*anton-kb83@mail.ru

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Vladimir L. Lemenev, Viktor A. Luk'ianchikov, Anton A. Beliaev*

Sklifosovsky Research Institute of Emergency Medicine, Moscow, Russia
*anton-kb83@mail.ru

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