Taufan Hidayat
Bedah Toraks Kardiovaskuler
Rumah Sakit Jantung Nasional Harapan Kita
Universitas Indonesia
Latar Belakang
ESVS 2017 guidelines merekomendasikan CEA untuk
pasien stenosis karotid berat simtomatik dan
asimtomatik dengan kondisi tertentu (stenosis 60 –
99% tanpa gejala)
Pasien asimtomatik memiliki luaran : stroke, kematian,
dan IMA yang lebih baik dibandingkan pasien
simtomatik
Analisa Statistik
CREST : Carotid Revascularisation Endarterectomy vs. Stenting Trial, ESVS : European Society for Vascular Surgery
Etiologi stroke peri-operatif
• Hemoragik atau infark?
• Jika infark, apakah terjadi di daerah MCA dan
akibat ruptur plak?
• Apakah disebabkan hipoperfusi? Akibat klem
arteri karotid internal atau variasi tekanan
darah?
• Apakah terdapat dampak komorbid dan
pengobatan, terutama antiplatelet?
Keterbatasan
Sebagian besar studi merupakan studi kohort
observasional, sebagian dengan desain retrospektif
(A) Definition of high plaque by Hans et al. The ICA is divided into three zones, with high plaque defined
as that located above Zone 2.
(B) Various definition of high plaque. Yellow line is the mastoid-mandibular line. Red line is the
intersection of the occipital artery and internal carotid artery. White line is the C1 transverse process-
hyoid bone line.
Intraoperative Monitoring
Intraoperative monitoring for CEA :
- MEP (motor-evoked potential)
- SEP (somatosensory evoked potential)
- NIRS (near-infrared spectroscopic topography)
MEP electrode; yellow arrows, electrodes for SEP; blue arrow, electrode for NIRS;
green arrow, electrode for BIS
Metode Klasik/Konvensional
OA : occipital artery, SMA : sternocleidomastoid muscle artery, ICA :internal carotid artery
Metode Eversi
• Transeksi arteri karotid pada
bifurkasio
• Dinding pembuluh darah di
sekitar plak dieversi
• Plak dibagi dan diangkat
• Arteri dihubungkan kembali
dengan end to end
anastomosis
• Keuntungan
▫ Tidak butuh patch closure
▫ Waktu klem dan operasi lebih
singkat
Temporary
Bypass Shunt
Terima Kasih
Stenting for symptomatic carotid stenosis is associated with a higherrisk of
periprocedural stroke or death than endarterectomy.
This extra risk is mostly attributed to an increase in minor, non-disabling
strokes occurring in people older than 70 years.
Beyond the periprocedural period, carotid stenting is as eFective in
preventing recurrent stroke as endarterectomy.
However, combining procedural safety and longterm eFicacy in preventing
recurrent stroke still favours endarterectomy.
In people with asymptomatic carotid stenosis, there may be a small increase
in the risk of periprocedural stroke or death with stenting compared with
endarterectomy. However, CIs of treatment eFects were wide and further
data from randomised trials in people with asymptomatic stenosis are
needed.