Problematik höhergradiger Karotisstenosen vor kardiochirurgischen Eingriffen – Konservative, katheterinterventionelle oder chirurgische Versorgung

Das Risiko eines Schlaganfalls während oder nach koronarer Bypass–OP ist bei Patienten mit koexistierender Karotisstenose deutlich erhöht, wobei in ca. 50  % dieser Fälle der Schlaganfall potenziell auf die Karotisstenose zurückgeführt werden kann. Die kombinierte Revaskularisation wird bei symptomatischer Karotisstenose und bei > 80  %igen asymptomatischen Stenosen von einigen Zentren mit guten Ergebnissen durchgeführt, dennoch liegt die Gesamt–Komplikationsrate bei diesen Patenten mit ca. 10  % relativ hoch. Eine Alternative könnte die endovaskuläre Behandlung mit Stent–Implantation vor dem herzchirurgischen Eingriff darstellen. Dieses Verfahren bedarf aber einer besonderen Planung aufgrund der erforderlichen dualen Plättchenaggregations–Hemmung.

Aus den bisherigen Daten können keine klaren Empfehlungen abgeleitet werden. Ein randomisierter Vergleich des konservativen mit einem invasiven Vorgehen (Operation oder Stenting) wäre wünschenswert, wird jedoch aufgrund der relativ kleinen Zahl an kombinierten Eingriffen kaum zu erwarten sein. Somit wird auch in Zukunft die optimale Therapie am besten durch ein multidisziplinäres Team, bestehend aus Internisten/Kardiologen, Neurologen, Chirurgen und Interventionalisten, für jeden Patienten individuell und in Abhängigkeit von der lokalen Expertise festgelegt werden.

There is a definitely increased risk of stroke during or after coronary bypass surgery in patients suffering simultaneously from carotid occlusive disease. In approximately 50  % of such cases the stroke is considered to be potentially due to the stenosis of the carotid artery. Some clinical centers have achieved good results with combined revascularization in cases of symptomatic carotid occlusive disease and in more than 80  % of non–symptomatic stenoses. However, the total rate of complications in such patients is relatively high, namely, approximately on a ten per cent level. An alternative could be an endovascular treatment with stent implantation before cardiac surgery. However, this demands specific pre–planning– due to the fact that it involves the need for inhibiting platelet aggregation.

No definite recommendations can be given on the basis of available data. It would be desirable to have a randomized comparison of conservative and surgical (surgery or stenting) procedures, but this is hardly likely in view of the relatively few combined interventions. Hence, optimal treatment will continue to be determined by a multi–disciplinary team of internal medicine experts/cardiologists, surgeons, and interventional experts, individually for each patient and depending on local expertise.

Key words

Carotid occlusive disease - carotid artery - cardiac surgery - stent implantation - surgery - stenting

Literatur

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