Sollen asymptomatische Karotisstenosen operiert werden?

Zusammenfassung

Anders als bei dem wissenschaftlich bewiesenen Nutzen einer Karotisendarterektomie (CEA) für Patienten mit mittel- und hochgradigen symptomatischen Stenosen der Arteria carotis interna (ACI) bestehen Zweifel, ob asymptomatische ACI-Stenosen nicht doch entgegen der Studienlage operiert werden sollen. Aktuelle Metaanalysen, welche alle vollständigen randomisierten Studien analysierten, die den Effekt der CEA einer konservativen (nichtchirurgischen) Therapie gegenüberstellten, kamen übereinstimmend zu dem Schluss, dass es zwar eine gewisse Evidenz zugunsten eines chirurgischen Vorgehens bei der Behandlung der asymptomatischen ACI-Stenose gebe, die aber gemessen an der absoluten Risikoreduktion nicht signifikant ist. In der vorliegenden Übersicht werden die Ausgangsdaten und Ergebnisse der Metaanalysen referiert und die z. T. kontroversen Empfehlungen diskutiert. Danach lässt sich eine individuelle Entscheidung im Rahmen eines experimentellen operativen Vorgehens nach sorgfältiger Risikoabwägung in Einzelfällen rechtfertigen, welche neben messbaren Parametern (z. B. in einem Algorithmus wie er für symptomatische Stenosen verwendet wird) auch persönliche Einstellungsfragen berücksichtigen muss. Zusammengefasst bleibt festzustellen, dass mit den gegenwärtig verfügbaren veralteten Originaldaten eine Argumentation in die eine oder andere Richtung nicht mehr auf vernünftiger Basis möglich ist. Deshalb sind neue Studien sinnvoll, für welche neben größeren Patientenzahlen intelligente Designs und niedrige individuelle Risiken nötig sind.

Abstract

In contrast to the proven benefit of carotid endarterectomy (CEA) in patients with middle- and high-grade symptomatic stenoses of the internal carotid artery, there exist controversies about the use of this procedure in asymptomatic patients which is not supported by study data. Recent metaanalyses compared all completed randomized studies which analysed the effect of CEA in comparison to conservative management, and concluded that there is a certain evidence in favour of the surgical procedure in the treatment of asymptomatic internal carotid stenosis, which, however, is not significant with regard to absolute risk reduction. In this review, we report on the original data and the results of metaanalyses and discuss the controversial recommendations. Accordingly, an individual decision for an experimental surgical therapy after a thorough risk-modelling analysis may be justified, which, apart from measurable parameters (e. g. in an algorithm as it is used in symptomatic carotid stenosis patients), has to consider individual patient's attitudes towards medical vs. surgical management. In conclusion, on the basis of outdated original data a reasonable argument in favour or against the procedure is no longer possible. This points to a need of new large studies with intelligent designs and low individual risks.

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