Karotis Arter Stentleme: Güncel Kılavuzlar ve Uygulama İlkeleri
Özet
Karotis arter stentleme (CAS), aterosklerotik karotis darlığının yönetiminde karotis endarterektomisine (CEA) minimal invaziv bir alternatif olarak öne çıkmaktadır. İskemik inmelerin başlıca nedenlerinden biri olan karotis darlığında CAS, büyük randomize çalışmalar (CREST, ACST-2, EVA-3S) ile etkinliği kanıtlanmış olup, cerrahiye benzer uzun dönem sonuçlar sunmaktadır. Güncel kılavuzlar (CIRSE 2024, ESVS 2023, ESO 2021), hasta seçiminin bireyselleştirilmesini, multidisipliner yaklaşımı ve emboli koruma cihazlarının rutin kullanımını vurgulamaktadır. CAS; yüksek cerrahi riski olan, cerrahiye uygun olmayan ya da restenoz, radyasyona bağlı stenoz gibi özel durumlarda değerli bir seçenektir. Modern medikal tedavi ve endovasküler teknolojilerle inme riski belirgin azalmış, komplikasyon yönetimi ve uzun dönem takip standartları oturmuştur. Teknolojik gelişmelerle birlikte CAS’in gelecekte daha seçici hasta gruplarında uygulanması öngörülmektedir.
Referanslar
Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, et al. European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg. 2023;65:7-111.
Bonati LH, Kakkos S, Berkefeld J, de Borst GJ, Bulbulia R, Halliday A, et al. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis. Eur Stroke J. 2021;6(2):I.
Baek JH. Carotid Artery Stenting for Asymptomatic Carotid Stenosis: What We Need to Know for Treatment Decision. Neurointervention. 2023;18(1):9–22.
North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high grade carotid stenosis. N Engl J Med. 1991;325:445–53.
European Carotid Surgery Trialists’ Collaborative Group. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70–99%) or with mild (0–29%) carotid stenosis. Lancet. 1991;337:1235–43.
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA. 1995;273:1421–8.
Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial. Lancet. 2004;363:1491–502.
Halliday A, Bulbulia R, Bonati LH, Chester J, Cradduck Bamford A, Peto R, et al.; ACST 2 Collaborative Group. Carotid artery stenting versus endarterectomy in patients with asymptomatic carotid stenosis (ACST 2): a randomised trial. Lancet. 2021;398:1065–73.
Brott TG, Hobson RW, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid artery stenosis. N Engl J Med. 2010;363:11–23.
Mas JL, Chatellier G, Beyssen B, Branchereau A, Moulin T, Becquemin JP, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis (EVA 3S). N Engl J Med. 2006;355:1660–71.
Rosenfield K, Matsumura JS, Chaturvedi S, Riles T, Ansel GM, Metzger DC, et al. Randomized trial of stent versus surgery for asymptomatic carotid stenosis. N Engl J Med. 2016;374:1011–20.
Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, et al. Protected carotid artery stenting versus endarterectomy in high risk patients. N Engl J Med. 2004;351:1493–501.
Eckstein HH, Reiff T, Kleinschmidt R, Mansmann U, Hacke W, Ringleb P, et al. SPACE 2: A randomized trial of stent protected angioplasty vs carotid endarterectomy vs best medical treatment in patients with asymptomatic carotid stenosis. Int J Stroke. 2008;3:294–9.
Spence JD, Naylor AR. Endarterectomy, stenting, or neither for asymptomatic carotid artery stenosis. N Engl J Med. 2016;374:1087–8.
Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis. Stroke. 2009;40:e573–83.
Spiliopoulos S, Blanc R, Gandini R, Müller Hülsbeck S, Reith W, Moschovaki Zeiger O. CIRSE Standards of Practice on Carotid Artery Stenting. Cardiovasc Intervent Radiol. 2024;47:705–16.
