Update – Therapie der Karotisstenose

Zusammenfassung

Die Karotisstenose ist für 20 bis 25 % aller Schlaganfälle verantwortlich. Eine optimale medikamentöse Therapie (OMT) ist bei allen Patienten mit Karotisstenose indiziert. Symptomatik und Stenosegrad sind die wesentlichen Parameter, die für die Indikationsstellung zu einer zusätzlichen operativen oder katheterinterventionellen Therapie entscheidend sind. Die Operation oder das Stenting bei hochgradiger, jedoch asymptomatischer Karotisstenose im Sinne einer Primärprävention sollte nur in Zentren erfolgen, die eine sehr niedrige, d. h. kleiner 2 % betragende, periinterventionelle Schlaganfallrate nachweisen können. Es sollte der Einschluss dieser Patienten in die SPACE-2-Studie angestrebt werden. Bei aktuell divergierenden Bewertungen der amerikanischen bzw. europäischen Leitlinien orientiert sich die deutsche kardiologische Bewertung durch die DGK mehr an den Empfehlungen der amerikanischen Fachgesellschaften, da die dieser Leitlinieneinschätzung zugrunde liegenden amerikanischen Studien der Behandlungsqualität erfahrener deutscher Zentren mehr entsprechen.

Abstract

Carotid artery stenoses account for 20 to 25 % of strokes. An optimal medical therapy (OMT) is indicated for every patient with such stenosis. The indication for an additional invasive therapy, e.g. surgery or stenting, is mainly dependent on the symptomatic status of the patient and on diameter according to the NASCET trial. In asymptomatic patients with > 70 % stenosis intervention should only be performed in centers with a documented low periinterventional stroke rate of < 2 %. Moreover, those patients should be treated in a randomized fashion within the SPACE-2-trial, whenever possible. Regarding the preference for surgery over stenting the current guidelines from American societies and the ESC have different recommendations. While the American guidelines are rather neutral, regarding both revascularization strategies mainly based on the results of CREST, the ESC and accordingly the German AWMF favor thrombendarterectomy over stenting based on EVA-3S, SPACE and ICSS disregarding severe methodical limitations of these European studies. The German Society of Cardiology (DGK) follows more the American perspective based on the large positive experience within the German carotid registries (GeCAS and the former BAQ and ALKK registries).

Schlüsselwörter

Karotisstenose - Karotisendarteriektomie - Karotisstenting - optimale medikamentöse Therapie

Key words

carotid artery stenosis - thrombendarterectomy - carotid stenting - optimal medical therapy (OMT)

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