Revascularization là gì

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Atherosclerosis affects all major vascular territories. Both surgical and endovascular revascularization techniques have sầu evolved, with more and more patients presenting with disease in multiple vascular beds. This can lead to lớn difficult decision-making & the potential for complications. In this article, we reviews the available literature lớn help the clinician decide on optimum sequence, timing, and mode of multisystem revascularization.

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INTRODUCTION

The diagnosis and treatment of vascular disease in the aorta, carotid, coronary, renal, & peripheral arteries is associated with reductions in morbidity & mortality. Because atherosclerosis is a systemic process, patients often present with disease involving more than one vascular bed (Table ).1 In this situation, the clinician is often faced with a dilemma regarding the optimum sequence, timing, và mode of multisystem revascularization. The alặng of this article is to lớn Reviews the available literature on this topic.

Prevalence

Aao ước patients with symptomatic coronary artery disease (CAD), 10% khổng lồ 20% have >70% carotid artery stenosis (CAS).2,3 Aý muốn patients awaiting coronary artery bypass grafting (CABG) procedures, 17% lớn 22% have ≥50% CAS and 6% khổng lồ 12% have ≥80% CAS.4,5 The prevalence of CAD in patients awaiting carotid endarterectomy (CEA) procedures is 35% to 45%.6,7

Timing of Concomitant Coronary & Carotid Revascularization

In a patient requiring both carotid & coronary revascularization, the sequence of procedures is generally dictated by the stability of the vascular beds, with the preference being to lớn revascularize the more unstable vascular bed first. This approach is based on data showing poor outcomes when revascularization is deferred in these situations. In patients with CAS clinically manifesting as transient ischemic attaông chồng, stroke risk is markedly higher compared with that of an asymptomatic patient with CAS, with the highest risk immediately following the initial ischemic sự kiện. In one study, 11% of patients developed a stroke within 90 days after a transient ischemic attachồng, with 50% occurring within the first 48 hours.8 In patients with symptoms of ađáng yêu coronary ischemia, coronary revascularization via either a surgical or percutaneous route has been shown to lớn be superior khổng lồ medical therapy.9–12

Planned Coronary Revascularization và Concomitant Carotid Artery Disease

When percutaneous coronary intervention (PCI) is chosen as the mode of coronary revascularization, the risk of periprocedural stroke is 0.3% to lớn 0.4%.13,14 There are no data suggesting increased stroke rates in patients with concomitant CAS undergoing PCI. Hence, screening for CAS prior lớn PCI is not recommended. If a patient presents for PCI with documented CAS, simultaneous or staged carotid intervention can safely be performed with the mode, sequence, và timing of the procedure determined by the anatomy and stability of the vascular beds.15–18

When CABG is planned, carotid duplex screening is recommended prior to lớn elective surgery in asymptomatic patients with any of the following criteria: age >65 years, left main stenosis, peripheral arterial disease, history of smoking, & history of transient ischemic attaông xã, stroke, or carotid bruit.19 Carotid revascularization is recommended before or concomitant khổng lồ elective sầu CABG in patients with symptomatic carotid stenosis >50% or asymptomatic carotid stenosis >80%.đôi mươi However, it should be noted that 50% of strokes occurring after CABG occur from other causes, such as atheroemboli.21 Aortic cross-clamping, atrial fibrillation, và duration of bypass are other important risk factors for stroke occurring during CABG.22–24

Carotid revascularization in patients awaiting CABG can be surgical or percutaneous. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines bởi vì not discuss mode but vị suggest that carotid revascularization should precede coronary revascularization when significant carotid disease is present, except in the uncommon situation of the emergent CABG patient, in whom CEA should closely follow CABG.20

Carotid artery stenting has emerged as an attractive sầu alternative khổng lồ CEA. Potential issues with this procedure in patients with concomitant CAD are hemodynamic compromise leading khổng lồ exacerbation of coronary ischemia và duration of antiplatelet therapy.25,26 Because dual antiplatelet therapy after CAS is recommended for 4 weeks, CABG may be delayed during that time.27–29 Anecdotal reports have shown surgery lớn be safe in patients receiving clopidogrel with carotid stenting done 1 to 5 days prior to surgery.30 Current data vày not show an advantage of staged CAS-CABG as compared with staged CEA-CABG.31–34

Planned Carotid Revascularization and Concomitant Coronary Artery Disease

Stress testing to lớn detect asymptomatic CAD is not indicated prior to elective sầu carotid revascularization. The ACC/AHA 2007 preoperative guidelines consider elective sầu CEA to be a low-risk surgery in which one can proceed without cardiac assessment provided there are no high-risk features such as decompensated congestive sầu heart failure, unstable angimãng cầu, recent myocardial infarction, uncontrolled arrhythmias, or severe valvular disease.35

During evaluation, if a patient scheduled for carotid revascularization is found lớn have symptoms suggestive sầu of coronary ischemia, then the priority is to revascularize the more unstable bed first. In a patient with symptomatic carotid stenosis và concomitant symptomatic CAD, assessing the stroke risk can help guide timing of revascularization. Markers of increased stroke risk include male sex, irregular carotid plaque, increasing age, contralateral occlusion, >90% CAS, hemispheric symptoms, cortical stroke, và more than 6 months of recurrent symptoms.36

Simultaneous Coronary and Carotid Revascularization

For the unstable patient with both ađáng yêu coronary ischemia and symptomatic carotid stenosis, simultaneous coronary and carotid revascularization may be performed, with best outcomes seen with percutaneous revascularization of both vascular beds.15–18,37,38

Summary

Optimal treatment has yet lớn emerge despite various reports in 110 publications và with more than 9,000 patients treated during the past 30 years.đôi mươi,39,40 Revascularization needs khổng lồ be individualized, and the most unstable vascular bed should be addressed first.

CAROTID ARTERY REVASCULARIZATION AND AORTIC ANEURYSM REPAIR

Prevalence

The prevalence of abdominal aortic aneurysm (AA) in patients with CAS >50% ranges between 9% và 20%.41–43 The prevalence of CAS that is >60% in patients with AA is 2% to lớn 9%.41,44–46

Timing of Concomitant Carotid Revascularization & Aortic Aneurysm Repair

For patients with both CAS & AA, no guidelines exist lớn guide timing of revascularization. No large observational studies or trial data were identified during the literature search. If both symptomatic AA and CAS are present, as with an aortic dissection involving the carotid artery, concomitant treatment is necessary, with a few case reports showing the feasibility of this approach.47,48

Planned Carotid Artery Revascularization and Concomitant Aortic Aneurysm Repair

Current guidelines vị not discuss screening for AA in patients undergoing elective sầu carotid revascularization.19 If an AA is detected in a patient awaiting elective carotid revascularization, the sequence of procedures should be guided by symptoms. For symptomatic carotid stenosis, CEA can precede or be performed simultaneously with AA repair with good outcomes.43,49–51 Data are lacking khổng lồ support the use of carotid artery stenting in this situation. For patients with asymptomatic CAD awaiting CEA who have an incidental finding of AA meeting the criteria for repair, current data suggest that CEA can be safely deferred for AA repair, provided that CAS is <80%.49 For asymptomatic stenosis >80%, the data are conflicting.49,51

Planned Aortic Aneurysm Repair and Concomitant Carotid Artery Disease

Current guidelines tư vấn screening for atherosclerotic carotid stenosis prior to lớn AA repair only in patients with history of transient ischemic attack, prior ischemic strokes, or retinal ischemic events.41

If CAS is detected in a patient awaiting elective sầu AA repair, the sequence of procedures should be guided by symptoms. In a patient with symptomatic atherosclerotic carotid stenosis, carotid revascularization takes precedence.51 In a patient with an incidental finding of asymptomatic CAS, carotid revascularization can be deferred for AA repair, provided carotid stenosis is <80%.41,52

We did not find any published literature on carotid artery stenting for atherosclerotic carotid disease in patients awaiting elective AA repair.

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Simultaneous Carotid Revascularization và Aortic Aneurysm Repair

Published data reveal no difference in outcomes when CEA precedes or is performed simultaneously with surgical AA repair.43,50,53 Simultaneous carotid stenting và AA repair (open or endovascular) have sầu been described in case reports of patients presenting with aneurysms of the aortic arch needing carotid stenting for anatomical reasons. In this case, the sequence depends on the urgency of aneurysm repair and symptoms of cerebral malperfusion.54–59

Summary

Screening and treatment of atherosclerotic carotid artery disease is indicated prior to elective AA repair only in patients with symptoms of carotid artery disease.

Simultaneous repair of symptomatic carotid stenosis is feasible. Treatment of asymptomatic carotid stenosis <80% in patients needing AA repair can be deferred. For asymptomatic carotid stenosis >80%, CEA, either preceding AA repair or simultaneous AA repair, appears khổng lồ be safe. In patients with both symptomatic AA and carotid stenosis, the sequence of revascularization is guided by severity of symptoms.

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CAROTID ARTERY AND RENAL ARTERY REVASCULARIZATION

Prevalence

In an autopsy study of 346 patients with stroke, 36 (10%) of the patients had renal artery stenosis (RAS) ≥75% and 101 (29%) had CAS >50%. Patients with CAS were 4 times more likely to have sầu RAS.60 Other studies have shown the prevalence of RAS in patients with significant carotid artery disease to range from 7% lớn 27%.60–62

Planned Carotid Revascularization & Concomitant Renal Artery Disease

Renal insufficiency is a known marker of increased morbidity và mortality in patients undergoing carotid revascularization. Perioperative sầu death & stroke rates in patients with renal insufficiency (serum creatinine ≥1.5 mg/dL) undergoing CEA are 2% to lớn 7%, & 2-year survival is 41%.62–67 Because of poor short-term and long-term outcomes, carotid revascularization in patients with impaired renal function, especially if asymptomatic, is debated.65 The theoretical benefits of identifying and treating RAS in patients awaiting carotid revascularization are improvement of renal function và better blood pressure control with renal revascularization.

There are no randomized trials or natural history studies khổng lồ guide management for these patients, và current guidelines vày not recommkết thúc screening or treatment of RAS prior khổng lồ elective carotid revascularization.68

Planned Renal Revascularization & Concomitant Carotid Artery Disease

In a patient with significant RAS, screening for carotid disease prior to lớn revascularization is not recommended.68,69

Simultaneous Carotid & Renal Revascularization

There is a pauđô thị of data regarding simultaneous revascularization of both vascular beds. Small case series have shown the safety and feasibility of this approach.70

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