Πόσο σίγουροι είμαστε για το όφελος της ενδαρτηρεκτομής στην ασυμπτωματική καρωτιδική στένωση; Γεώργιος Ντάιος Παθολογική Κλινική & Ομώνυμο Ερευνητικό Εργαστήριο Ιατρική Σχολή Πανεπιστημίου Θεσσαλίας Αθήνα 30/11/2013

Disclosures Support to attend educational activities: Bayer; Sanofi-Aventis; Pfizer; Lundbeck; Boehringer-Ingelheim; Galenica; Elpen; Bristol Myers Squibb. Honoraria: Quintiles; Medtronic. Speaker fees: Sanofi Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis. Participation in trials – National coordinator (Greece) for the ENOS trial. – Sub-investigator (AMGEN, ).

JAMA 1995; 273:

ACAS: Asymptomatic Carotid Artery Study JAMA 1995; 273: % 11%

Lancet 2004; 363: 1491–502

ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

Stroke 2011; 42(8):e

It is reasonable to perform carotid endarterectomy in asymptomatic patients with >70% internal carotid artery stenosis if the risk of perioperative stroke, MI, and death is low. (Level A, Class IIb) Stroke 2011; 42(8):e

ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

Number-Needed-to-Treat: 40 (to prevent 1 stroke in 5 years)

Best (???) medical treatment

Lancet 1996; 348: 1329–39

CAPRIE: Clopidogrel vs. Aspirin Lancet 1996; 348: 1329–39

Best (???) medical treatment - Better antiplatelets are available now

ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

ACST: Asymptomatic Carotid Surgery Trial Lancet 2004; 363: 1491–502

Stroke 2008; 39: 3297–3302

Best (???) medical treatment - Better antiplatelets are available now - 30% did not receive statin

Excellent safety record  an annual minimum of 12 carotid endarterectomies  mortality/morbidity rate <3% in the last 50 cases.  40% of initial applicants were rejected  2 strokes/deaths  temporarily suspended ACAS: Asymptomatic Carotid Artery Study

Stroke 2009; 40:e573– e583

International Journal of Stroke 2009; 4:

International Journal of Stroke 2013, e-pub ahead of print

Degree of stenosis Stroke 2000; 31:

Plaque surface

Stroke 2011; 42: Total plaque area

Stroke 2006; 37:

Radiology 2009; 252: 502-8

Intraplaque hemorrhage Radiology 2009; 252: 502-8

Lancet Neurol 2010; 9: 663–71 Microembolic signals

Lancet Neurol 2010; 9: 663–71

Microembolic signals Lancet Neurol 2010; 9: 663–71

Silent strokes J Vasc Surg 2009;49:902-9

Silent strokes J Vasc Surg 2009;49:902-9

-Degree of stenosis -Plaque surface -Total plaque area -Fibrous cap -Intraplaque hemorrhage -Microemboli -Silent strokes

Take home messages