Indicazioni non differibili a Chirurgia Carotidea

Surgery of Carotid Endarterectomy (CEA) has shown, through prospective randomized trials, its undisputed efficacy in the prevention of stroke in elective, hemodynamically significant carotid stenosis in symptomatic, as also in asymptomatic patients, provided that the complication rate correlated to the intervention is limited. Still controversial is the indication for CEA in emergency, in the acute phase of cerebral ischemia, due to the risk of hemorrhagic conversion of ischemic infarct, with a poor prognosis. A growing number of positive experiences reported in the literature seems to authorize the extension of indication for CEA in urgency to subjects with ischemic neurological symptoms, without altered state of consciousness, and within the first hours of the event. But there are also indications to CEA, which "can not be postponed". Those are clinical conditions characterized by repeated ischemic attacks and / or by the presence of unstable carotid plaques. Prospective studies that have looked at the natural history of carotid atherosclerotic plaque, in relation to related cerebral ischemic events, showed some morphological features correlated with a higher percentage of embolic cerebral ischemia. The purpose of this study was to determine, based on personal experience and published studies, which are the morphological characteristics of unstable carotid plaque, that require intervention of CEA in a short time. Some pathological features of the evolutionary process of carotid plaque, defined with good reliability through the Doppler examination, have shown greater correlation with cerebral ischemia. These features are: lower plaque echogenicity as defined by GSM index, the prevalence of "soft core" with a thin capsule surface, intramural hemorrhage, ulceration, aspects of thrombotic appositions in the luminal surface. We must therefore conclude that for indication to surgery, in addition to the usual criteria of percentage of stenosis and carotid related neurological symptoms, should always be considered the "third parameter", ie the morphology of the plaque. The morphological characteristics described above define in fact the so-called "carotid plaque at risk" of cerebral ischemia, in the presence of which the indication to carotid endarterectomy cannot be postponed.

L’indicazione a CEA in elezione è ormai stabilmente accettata e comprende: stenosi carotidee emodinamicamente significative sintomatiche ed asintomatiche; l’indicazione in emergenza è ancora fortemente discussa e si riferisce alla tromboembolia carotidea, entro le prime ore da uno stroke in progresso, senza alterazioni di coscienza. Accanto a questa va a nostro avviso considerata l’indicazione “non differibile” a CEA, basata non tanto sui parametri di sintomatologia neurologica e percentuali di stenosi, anche se importanti, quanto soprattutto sugli aspetti morfologici di “placca carotidea instabile”. Numerosi studi hanno confermato che le placche molli, a core lipidico, emorragico o colliquato, con capsula sottile, con grossolane ulcerazioni, e la presenza di trombo sulla superficie, sono correlate ad un alto rischio d’embolia cerebrale. La dimostrazione di tali aspetti morfologici, accertabile con piena attendibilità con Ecodoppler, indica la necessità di CEA non differibile, confermando l’importanza del terzo parametro: la morfologia della placca, oltre a sintomatologia neurologica e percentuale di stenosi, nell’indicazione chirurgica