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J M CARDON PRIVATE HOSPITAL FRANCISCAINES NIMES FRANCE
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First cause of mortality cardiac events: 683 170 Second stroke : 372 534 Third cancer: 293 602 Infografika 2012
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TCMM 1977 Easton JD 21,1%
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TCMM Série Historique 1977 Easton 6,5 % 2,8 % 2,8% 2006 EVA 3S 3,9 % 15000 cases in France NASCET 1991 ACAS 1995 EVA 3 S 2006
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Symptomatic stenoses NASCET2885 patients1987-1996 ECST3024 patients1981-1994 Asymptomatic stenoses ACAS1659 patients1987-1993 ACST3125 patients1995-2003
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Sténoses > 70 % NASCET2885 patientsNEJM 1991 ECST3024 patients Lancet 1991 ↓ R. Abs ↓ R. Relat NST / 1 stroke stroke Avoided for 1000 CEA NASCET 17 %65 % 6 170 ECST8,5 %*45 %1283
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Sténoses 50-69 % NASCET858 patientsNEJM 1998 ECST646 patients Stroke 2003 ↓ R. Abs ↓ R. Relat NST / 1 sroke sroke Prevented by 1000 CEA NASCET 8,4%26% 12 83 ECST 5,7% - - -
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Age > 75 (Nascet NST 3 vs 6) stroke vs TIA men vs women central vs retineal
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<2 sem2-4 sem4-12 sem>12 semp ECST6,5%6,4%7,4%8%0,86 NASCET7,1%5,0%6,5%7,4%0,64 Total6,9%5,7%7,0%7,8%0,48
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Reduction of absolute risk of stroke and mortality at 5 years according to the delay of surgery Rothwell : stroke 2004
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Stroke risk 7 days10 % 30 days15 %
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Angio MRI or scan in less than 24 h Duplex doppler Cardiac screening Hospitalisation if ABCD2 ≥ 3
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ACAS1995Jama ACST-12004Lancet 2010 Level 1 grade A evidence supporting CEA In highly selective asymptomatic patents with a stenosis > 60 % CEA conferred a 50 % relative risk reduction of stroke at 5 years
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Sténoses > 60 % ACAS1662 patientsJAMA 1995 ACST3120 patients Lancet 2004 ↓ R. Abs ↓ R. Relat NST / 1 AVC stroke Avoided for 1000 CEA ACAS 5,9 %53 %1953 ACST5,4 %45 %1854
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Subgroup analysis Degre of stenosis does not influence the results better for men vs women (↓ r.a 8 / 1,4 %) benefit arrive after 1 years younger <75 years have more benefit than older
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USA 2005 Endartériectomie 135 701 92 % asymptomatique
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With the use of statins in ACTS-1 The evidence of stroke fell strongly in the medical arm But it fall strongly as well is the CEA arm. So the difference is still highly significant
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NO BENEFIT FROM CEA Symptomatic Asymptomatique < 50% NASCET < 60% NASCET
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R. AbsR. RelatNST / 1 stroke stroke Avoided by 1000 CEA NASCET 17 %65 % 6 170 ECST8,5%45%1283
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R. AbsR. RelatNST / 1 stroke Stroke avoided by 1000 CEA Sténoses Symptomatic 50-69 % NASCET 6,5%29% 15 67 Sténoses Asymptomatic > 60 % NASCET 5,9%53%17 59
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TIA are emergencies Symptomatic patient have to be treated within 15 days The degree of stenosis does not influence the stroke risk in asymptomatic patient with stenosis >60% TCMM must be < 3% to operate asymptomatic patient
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N TCMMResténose ou occlusion Ballotta 1999 Eversion 16900 Patch 1672,3%4,9% Green 2000 Eversion 1070,9%4,6% Patch 1673%4,7% Everest Trial 2000 Eversion 6782,2%3,6% EC 6751,6%9,2% Cochrane DB 2003 Eversion 11901,7%2,5% EC ± patch 11732,6%5,2% Cochrane 2003
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Pour LESS RESTENOSIS NO CLINICAL BENEFIT SURGEON CHOICE Notre opinion TECHNIC Eversion
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G
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N TCMM periop TCMM Fw-up Resténose occlusion Patch 9362,3 %13 %4,3 % Suture directe8333,7 %20 %13,7 % NSSS 2009
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MAY REDUCE RESTENOSIS AND OCCLUSION RATE REDUCE IPSILATERAL POST OP STROKE RATE REDUCTION IN POST OP TCMM RATE
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Dacron Collagène vs PTFE 2004
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2009
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Avantage : hémodynamic and morphologic data N AbnormalitiesFU (mois) RESTENOSE Normal vs minor abnormal Baker 1994 31619,6%21,64,3% vs 17% Ascher 2004 6502,3%--
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comparative study angioNo angio NTCMM %N Roon 1992 5351,3%1574,5% Ricco 1996 1120,9%1143,5%
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STROKE + DEATH +MI 30ème jour GA 4,8 % LA 4.5 % Quality of life (1 month) intervention time ICU stay hospital stay 3526 patients NO différence
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no major differrence between tecnics but eversion or systematic patch better than direct suture No proof for shunting :never,sometimes or always Local or geneneral anesthesia are equivalent Heparine reversal have no impact on stroke or MI risk
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NEVER FOR SYMPTOMATIC PATIENT: Eva 3s, space, icss, crest: Risk x 3 comparing with CEA Not for old > 80 years Anatomy suitable for CAS
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Registres prospectifs NTCMM Hobson (Crest) 99 12% 2004 Stanziali (Pittsburgh) 87 9,2% 2005 Gray (Capture) 594 7,9% 2006
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Equivallence with CEA in crest More than 100 CAS experience to get skills Answer with ACST 2 study: work in progres
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Progres in CAS 8F Transcervical Arterial Sheath 8F Venous Return Sheath Large bore flow reversal circuit Flow controller with stop, HI and LO flow
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CEA CAS 2010 88 20 2011 102 26 2012 86 43
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