karotid mikroendarterektomi endikasyon ve cerrahi teknik

ENDİKASYON VE CERRAHİ TEKNİK

KAROTİD MİKROENDARTEREKTOMİ

Turk Norosirurji Dernegi26. Bilimsel KongresiBelek Antalya 20-24 Nisan 2012

Prof. Dr. Nihat EGEMEN, Prof. Dr. Nihat EGEMEN, Ankara Universitesi Tıp Fak.Ankara Universitesi Tıp Fak.Beyin ve Sinir Cerrahisi A.B.D.Beyin ve Sinir Cerrahisi A.B.D.

EGEMEN

EKSTRAKRANİAL KAROTİS HASTALIKLARI

1- KAROTİS STENOZU a- İKA

b- ECA

2- KAROTİS TAM TIKANIKLIĞIa- KKAb- İKAc- EKA


İNTERNAL KAROTİD ARTER STENOZU

1. GEÇİCİ İSKEMİK ATAKLAR (GİA)• Hemisferik Ataklar• Geçici Körlükler (Amorozis Fugaks)• 7-10 dk. sürer 24 satten kısa.2. GERİ DÖNEN İSKEMİK NÖROLOJİK DEFİSİT (GİND)• 24 saat’ten fazla 3 haftadan az.3. İNME• Serebral infakt sonucu değişik şiddette kalıcı nörolojik

defisitler. EGEMEN


YOĞUN STENOZUN OLDUĞU VE GİA GEÇİREN

HASTALARDA SEMPTOMLARIN ORTAYA ÇIKMASINI

TAKİB EDEN 1. YILDAKİ İNME RİSKİ

% 12- 13

BEŞ YIL SONUNDAKİ TOPLAM İNME RİSKİ

% 30-35

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Completed1991StatusTrial complete. Initial results published 8/91.

Trial PhasePhase III

SponsorNational Institute of Neurologic Disorders and Stroke, NIH

NASCET North American Symptomatic Carotid Endarterectomy Trial

ResultsThe risk of ipsilateral stroke was reduced significiantly (p=0.045) in patients with carotid stenosis 50-69% who received carotid endarterectomy. Patients with stenosis of 70-99% showed the most significant reduction(p < 0.001) in the rate of ipsilateral stroke while patients with stenosis of <50% did not show a significantly lower rate of ipsilateral stroke.


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EKSTRAKRANİAL KAROTİS HASTALIKLARI

Arteriosklerozilerleyicidir


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Serebral İskemiSemptomatik Hasta

MRI+ Medikal ve Kardiak tetkik + aspirin

Semptom devam ediyor Semptom devam ediyorTıbbi ve Kardiak Neden var non Kardiak- Non medikal hasta

Uygun tedavi Angiografi

VertebroBaziler IKA oklüzyonu karotis Bif. Darlığı IKA oklüzyonu Normal

Aspirin/Coumadin

Semptomatik

MRI,Xenon BT,SKA çalışmaları

Ekstrakranial/ İntrakranialRekonstrüksiyon/Revaskülerizasyon

Güdük + EKA hast.

Stumpektomi+ EKA endarterektomi

Karotis Mikro-Endarterektomi

Güdüksüz Çok Az Hasta

Aspirin+Takip

Aspirin/ Coumadin

Semptomlar Devam ederseEGEMEN


EGEMEN

Semptomlar Devam ederse

Aspirin/ Coumadin

SPECT/MRI/ Xenon BT, SKA çalışması

Hipoperfüzyon/ İskemi var Hipoperfüzyon/ İskemi yok

Revaskülerizasyon-STA- MCA ANASTAMOZ- VEN GREFTİ İLE ANASTOMOZ

Medikal Tedavi ve takip


AMERİKA BİRLEŞİK DEVLETLERİNDE İLK KAROTİD ENDARTEREKTOMİ 1950 YILINDA YAPILDI

1971 YILINDA 17000 KİŞİYE1999 YILINDA 130.000 KİŞİYE KAROTİS ENDARTEREKTOMİ

YAPILMIŞTIR.TÜRKİYEDE YILDA *!!!!!!!!* ENDARETEREKTOMİ ?????

NEDEN AZ ?TÜRKİYEDE SENEDE 90-100 BİN YENİ İSKEMİK HASTA

GÖRÜLMEKTEDİR

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KLİNİĞİMİZDE VE TÜRKİYEDE KAROTİD MİKROENDARTEREKTOMİ İLK KEZ

PROF. DR. NURHAN AVMANTARAFINDAN 1974 YILINDA YAPILMIŞTIR!

(1974- 2012)

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AMELİYAT ÖNCESİ TANIKLİNİK BELİRTİ

NÖROLOJİK MUAYENE*RENKLİ KAROTİD DOPLER

*CT*MRI

MRA/** BTA/** DSA - BOYUN SEGMENTİ, - İNTRAKRANİAL ARTERİAL YAPI, - ARKUS ÇIKIŞLARI

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RENKLİ KAROTİD DOPLER


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MRI BT


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MRA DSA


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BT ANGİOGRAFİ PREOP


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BT ANGİOGRAFİ POST OP


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STENOZ

ANGİOPLASTİSONRASI


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DSA- VE DARLIK YÜZDESİ


Xenon CT ( Asetolozamid) SPECT MRI- perfüzyon MRI- difüzyon Serebral kan akımı

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MRI- T2 flair MRI- difüzyon ADC haritası

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1. HİPERTANSİYON

2. İSKEMİK VE KONJESTİF KALP HASTALIKLAR

3. DİABETES MELLİTUS

4. PULMONER HASTALIKLAR

YÖNÜNDEN DEĞERLENDİRİLİRLER

AMELİYAT ÖNCESİ

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AMELİYAT ÖNCESİ VE SONRASI DÖNEMDE

MEDİKAL TEDAVİ ASPİRİN 300 MG/GÜN

ASPİRİN VEREMEDİĞİMİZ HASTALARDA PLAVİX 75 mg KULLANMAKTAYIZ

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ENDİKASYONLAR

1-SEMPTOMATİK HASTALARİKA de % 70 ve üzeri darlık

İKA de C tip Ülser ve medikal tedaviye rağmen GİA geçiren B tipi ülserler.

2- ASEMPTOMATİK HASTALARİKA de % 60 üzeri darlık

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MİKROSKOP YARDIMI İLE YAPILAN ENDARTEREKTOMİ

“KAROTİD MİKROENDARTEREKTOMİ”

MÜKEMMEL AYDINLATMA, MİKROSKOP ÇEŞİTLİ BÜYÜTMELERDE GÖRÜNTÜ VE ÇEŞİTLİ AÇILARDAN BAKIŞ SAĞLAR.

MİKROSKOP KAROTİD CERRAHİSİNİN VE MİKROCERRAHİ TEKNİĞİNİN ÖĞRENİLMESİNEDE YARDIMCIDIR

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KAROTİD ARTER TAMİRİNİ KOLAYLAŞTIRIR VE İYİLEŞTİRİR

DİSTAL KAROTİD ARTERİN DAHA İYİ GÖRÜNTÜLENMESİNİ,

ARTERİOTOMİNİN YAMA KULLANILMADAN KAPATILMASINI

VEİYİ DÖKÜMENTASYON SAĞLAR.

AMELİYAT SÜRESİNİ KISALTIR. ( 17 dak.)

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1. GENEL ANESTEZİ2. BEYNİ İSKEMİDEN KORUMAK AMACI İLE 250 mg. SODİUM THİOPENTAL (İV) .3. TROMBÜS OLUŞUM RİSKİNİ AZATMAK AMACI İLE 5000 İÜ. HEPARİN (İV) VERİLİR.4. KAN BASINCI TAKİBİ YAPILARAK HİPOTANSİYONDAN KAÇINILIR.5. EĞER KARŞI KAROTİS ARTER TAM TIKALI DEĞİL İSE ŞANT KULLANILMAZ.6. KAROTİD ARTER 6.0 PROLEN İLE YAMA KULLANILMAKSIZIN KAPATILIR.

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MİKRODOPLER


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ATEROM PLAĞI


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Aterom plaklarının iç yüzündeki ülserasyonlar


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PREOPPOST OP


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Primary closure after a carotid endarterectomy. Surg Today. 2007;37(3):187-91. Epub 2007 Mar 9. Kim DI, Moon JY Lee CH, Kim DY Jang YS, Kim GM, Chung CS Lee KH, Kim SWDivision of Vascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwondong, Kangnamku, Seoul, 135-710, South Korea.PURPOSE: The prevalences of restenosis and stroke after a carotid endarterectomy (CEA) tend to differ substantially according to the surgeon. Primary closure after a CEA was the routine procedure in our institute. The primary objectives of this study were to compare the results of patients of a primary arteriotomy closure in CEA between our own and others' results based on the findings in the literature. METHODS: One hundred and sixty-six patients who underwent a primary closure were analyzed. Perioperative neurologic deficits were determined by the neurologist. Restenosis was defined as >50% stenosis on duplex scan. The range of follow-up was 7-112 months. RESULTS: Stroke including transient ischemic attack occurred within 30 postoperative days in 3 patients and after 30 postoperative days in 1 of the 166 patients. Five patients showed >50% asymptomatic restenosis. Two patients were treated with stent insertion and one underwent reoperation. One patient showed total occlusion during the follow-up period without any neurological deficits. One patient showed 50%-70% stenosis, and no intervention was done. CONCLUSIONS: The rates of recurrent stenosis and postoperative stroke were found to be sufficiently low following a primary closure to justify the continued use of this technique

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Plavix+ asprin kullananhastada cilt altına sızıntı tarzında hematom


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MRI da İskemik bölge


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DSA da trombüs


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EKA STENOZU PREOP


Post op ICA da rekanalizasyonEGEMEN

EKA STENOZU POST OP


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Perspect Vasc Surg Endovasc Ther. 2006 Dec;18(4):300-3; discussion 304-5. Links Carotid stent trials: past, present, and future.Quirel KDivision of Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA. [email protected] stenting has emerged as a therapeutic alternative to standard carotid endarterectomy in patients with carotid bifurcation disease. The percutaneous modality holds the potential to replace a large proportion of the carotid surgical procedures performed throughout the world. Carotid stenting has undergone technologic advances in the last decade, including improved sheaths and guides, lower profile balloons and stents, and the almost ubiquitous use of dependable distal embolization protection devices. Contemporary data confirm the safety and efficacy of the procedure for patients with high-grade lesions who are at higher-than-normal risk for standard open carotid repair.

Whether lower-risk patients should be offered stenting as an alternative to carotid endarterectomy is a question that must await the results of ongoing clinical trials

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karotid mikroendarterektomi endikasyon ve cerrahi teknik

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