Symptomatische Karotisstenose

Zusammenfassung

Die extrakranielle Stenose der Arteria carotis interna (ACI) ist ein wichtiger Risikofaktor für ipsilaterale Schlaganfälle. Als Behandlungsoptionen stehen die Karotisendarteriektomie (CEA), das Karotisangioplastie- und -stenting (CAS) und die konservative, medikamentöse Therapie (mThx) zur Verfügung. Die Therapieentscheidung wird primär davon bestimmt, ob die Stenose symptomatisch ist. „Symptomatisch“ meint, dass konkrete Symptome unzweifelhaft auf die ipsilaterale Hirnhemisphäre zu beziehen und nicht älter als sechs Monate sind. Korrelate in der zerebralen Bildgebung können Hilfestellung bieten. Für die Risiko-Nutzen-Abwägung ist der Stenosegrad wesentlich. Bei symptomatischen ACI-Stenosen, die > 70% eingestuft werden, ist die CEA der mThx überlegen, wenn die Komplikationsrate der CEA < 6% liegt. Bei Stenosen mit Stenosegrad zwischen 50 und 70% ist ein Vorteil der CEA gegenüber der mThx geringer. Er ist bei Patientinnen, Patienten mit Diabetes mellitus, mit Nierenversagen oder mit Amaurosis fugax nicht mehr nachzuweisen. Die Entscheidung für eine CEA sollte bei Stenosen zwischen 50 und 70% deshalb besonders differenziert getroffen werden. Wenn, dann sollte eine CEA frühzeitig durchgeführt werden (< 14 Tage nach dem qualifizierenden Ereignis). Patienten mit symptomatischen Stenosen < 50% profitieren nicht von einer Operation. Bei asymptomatischen Stenosen > 60% besteht ein Vorteil der CEA gegenüber der konservativen Therapie, wenn die Komplikationsrate des Operateurs < 3% liegt und der Patient eine Lebenserwartung von mindestens fünf Jahren hat. Das CAS ist nach derzeitigem Stand der Technik der CEA nicht ebenbürtig. Die Studienlage wird in diesem Artikel zusammengefasst.

Summary

Extracranial stenosis of the internal carotid artery (ICA) is a major risk factor for ipsilateral ischemic stroke. Current treatment options include carotid endarterectomy (CEA), carotid angioplasty and stenting (CAS) and medical treatment (mThx). The choice of therapy should primarily depend on the clinical presentation. “Symptomatic” means, that unambiguous ipsilateral hemispheric symptoms are present and not older than 6 months. Correlates in brain imaging can be helpful. The benefit of CEA increases with the degree of the stenosis and if carried out early (< 14 days after the qualifying ischemic event). CEA is superior to mThx in ICA stenosis > 70%. The benefit depends on the complication-rate of the surgeon that needs to be below 6%. Patients with moderate ICA stenosis (50 to 69%) also benefit from revascularization except for female patients, diabetics, patients with renal failure, and patients with amaurosis fugax. Patients with stenosis < 50% do not benefit from CEA. CEA is of benefit in asymptomatic stenosis (> 60%) only, if the complication rate remains below 3%. Best available technology leaves CAS to be the second choice in patients with symptomatic stenosis of the ICA because current studies failed to prove non-inferiority. This article reviews the current body of evidence.

Schlüsselwörter

Arteria-carotis-interna-Stenose - Karotisendarteriektomie - Karotisangioplasie - Karotisstenting

Keywords

Internal carotid artery stenosis - carotid endarteriectomy - carotid angioplasty - carotid stenting

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