Conferencia Dr. Alejandro Cherro - Sanatorio Modelo Quilmes

SIMPOSIOS 2010
Revascularización Carotídea. Cuando y cómo.
Dr. Alejandro Cherro
Director Consejo Hemodinamia SAC
Enfermedad Carotídea
Prevalencia

Población general : 5% de enfermedad
carotídea.
Duplica el riesgo de Episodios Cerebro
Vasculares
Enfermedad Carotídea.

La estenosis u oclusión carotídea aterosclerótica
causa alrededor del 30% de las isquemias
cerebrovasculares.

La enfermedad estenosante de la arteria carótida
secundaria a placas de arteroma tiene alta
prevalencia apartir de los 50 años.

La progresión de esta enfermedad se ve
favorecida por la presencia de FRCV (sexo masc,
edad, DBT, DLP, TBQ, hiperhomocisteinemia).
Etiología
85 % Stroke son isquémicos.
30% de vasos mayores.
 35% enfermedad de pequeños vasos.
 20% Embolias cardio aórticas
 15% Causas Varias.
(Hipercoagulabilidad, infecciones, colagenopatias, etc.)

Revascularización Carotídea. Cómo?
Equipo multidisciplinario
 Estudio neurológico completo
 Estudio cardiológico completo.


Utilizando todos los métodos diagnósticos disponibles
posibles.
Equipo multidisciplinario
Neurólogo
 Cardiólogo Clínico
 Cardiólogo Intervencionista
 Neurocirujano
 Cirujano Vascular
 NeuroRadiólogo

Revascularización Carotídea. Cómo?
Métodos Diagnósticos

TAC de cerebro


Doppler (FP y FN 5 A 20%) , Doppler Tcr.
AngioRMN
AngioTAC multislice

ANGIOGRAFIA Extra e Intracraneal.

Revascularización Carotídea. Cómo?
Estudio neurológico completo

Examen clínico completo
Doppler
 TAC
 RMN.
 Estudios de Perfusión-difusión.

Examen clínico-neurológico completo

Presentación clásica:
Debilidad de brazo y cara contralateral que en
ocasiones puede afectar la pierna
Alteraciones mono oculares transitorias.
Síntomas no asociados:
Síncope, mareo, vértigo, alt sensitivas de brazo o
alteraciones cognitivas.
Revascularización Carotídea. Cómo?
Estudio neurológico completo
Stroke

–
Perfusión Cerebral

-
Acople o match P-D
-
Estudio de Perfusión .
-
Estudio de Viabilidad.
CORRELACION
DIFUSIÓN/PERFUSION
ACOPLE (MATCH)
DESACOPLE (MISMATCH)
Con un desacople del 49%, el beneficio fue
muy bueno;
Con uno
favorable;
del
28%,
la
evolución
fue
Con menos del 15%, no hubo beneficio;
Con menos del 8%, la evolución fue
desfavorable.
Trombo ACP
DEFUSE STUDY Albers GW et al
Ann Neurol 2006;60:508-517
Estudios de Perfusión-difusión.
Cómo?
La correlación volumétrica entre D-P, la denominamos
acople o match a la falta de acople mist match.
Una lesión en Difusión menor que la Perfusión, representa
menor daño bioenergético que oligohémico., mayor
beneficio con trombolisis.
Imágenes acopladas entre D-P aumentan la probabilidad de
infarto
Revascularización Carotídea. Cómo?
TAC

Debemos conocer la anatomía de las
estructuras cerebrales que queremos
tratar.

Evaluar parenquima normal, edema,
infartos, tumores,etc.
Examen Clínico cardiológico.
Detección de Cardioembolias.







Arritmias. Fibrilación Auricular
Aneurismas de septum interauricular.
FOP
Trombos cavitarios, trombos murales
Mixomas.
Tumores Cardíacos
Aneurismas de septum
Examen Clínico neuro cardiológico.
Detección de Cardioembolias.




Arritmias. Fibrilación Auricular
Aneurismas de septum interauricular.
FOP
Trombos cavitarios, trombos murales
 Mixomas.
Tumores Cardíacos
 Aneurismas de septum

ANEURISMAS MIXOMATOSOS
Angiografia Digital
EVALUACION ANGIOGRAFICA
Aortogram
4 Vessels
Revascularización Carotídea. Cómo?
Angiografía por RM
ANGIORM 3.0T

AUMENTO
DE RESOLUCIÓN

VISUALIZACIÓN
DE VASOS
PERIFÉRICOS|
ANGIORM VASOS DE CUELLO
2D
3D
Estudio comparativo entre CTA y MRA en
estenosis intracraneana
CTA %
MRA %
Sensibilidad
98 (98)
70 (70)
Especificidad
98 (99)
99 (97)
Valor predictivo positivo
78 (93)
63 (65)
Valor predictivo negativo
100 (100)
98 (98)
UCLA AJNR 2005; 26:1012-21
ESTRATIFICACION DEL GRADO DE
ESTENOSIS CAROTIDEA:
Normal.
 < 50% (placa no estenosante).
 50% a < 70%, estenosis moderada
 70% (estenosis severa).
 >95%Estenosis crítica o suboclusiva.
 100% (oclusión).

Angiografía Carotídea y vertebral intracerebral
DWI
MAPA DE ADC
ARM 3T
ANGIO RM 3DTOF
3 TESLA
3D TOF
VOLUME
RENDERING
Estenosis en el sifón carotídeo (Amaurosis Fugax)
Mujer de 51 años
Antecedente AIT antiagregado
Stroke isquémico
Displasia fibromuscular
Disección carotídea
Técnica. Cómo?
Acceso
SIMPOSIOS 2010
Revascularización Carotídea.
Cuándo y cómo?
Enfermedad Carotídea Sintomática

Estenosis carotídea 70 a 79% a 2 años riesgo de ACV 20%

Estenosis carotídea 80 a 89% a 2 años riesgo de ACV 28%

Estenosis carotídea 90 a 99% a 2 años riesgo de ACV 35%
Riesgo promedio a 2 años 26%
Enfermedad Carotídea Sintomática
Tto médico vs Endarterectomía

NASCET
EEUU

ECST
Europeo

VACS
Veteranos
Enfermedad Carotídea Sintomática
Beneficio a favor de la Endarterectomía vs.
tratamiento médico
En estenosis mayor o igual al 50%
Enfermedad Carotídea Sintomática

Estenosis 70 a 99% hubo un mayor
beneficio con Endarterectomía.

Estenosis 50 a 69% menor beneficio en
ACV-Muerte. (RR 10.1% a 5 años)
La Endarterectomía no esta indicada en lesiones menores al
50%
Pacientes Asintomáticos
ACAS
Lesiones mayores al 60%
Pacientes Asintomáticos: n 1662
ACV o muerte 11.1 vs 5.1%
Disminución de riesgo absoluto anual de 2 a 1%
RR hombres 66% RR mujeres 17%
Carótida Sintomática estenosis 70-99% : ACV o Muerte 5.7% a 10% anual
Postendarterectomía Riesgo 1% anual.
Metanálisis
Pacientes con estenosis asintomáticas >60% mostraron:

ACV muerte a 10 y 15 años 9.3 y 16.3%

IAM y muerte vascular a 15 años 25%
Esfuerzo en prevención del IAM y muerte
vascular
Endovascular versus surgical treatment in patients with carotid
stenosis in the Carotid and Vertebral Artery Transluminal
Angioplasty Study (CAVATAS):
Endovascular versus surgical treatment in patients with carotid
stenosis in the Carotid and Vertebral Artery Transluminal
Angioplasty Study (CAVATAS):


Estudio ramdomizado, multicéntrico Angioplastia vs.cirugía
en estenosis carotidea y vertebral.
504 pacientes. 251 Ang y 253 para tratamiento quirurgico.
26% stent , ninguno protección !!!

Sintomáticos (96% en ambos grupos) 6 meses previos a ramdomización.

La incidencia de eventos mayores a los 30 días no fue significativa entre en
tratamiento endovascular y cirugía

Neuropatia craneal fue reportada en 22 pts (8,7%) con cirugía pero no con
tratamiento endovascular.

Un año después de segmimiento estenosis severa ipsilateral (70-99%) fue
más común en tto endovascular 25 pts (14%) vs 7 (4%).


El tratamiento endovascular no tuvo diferencias significativas en la
incidencia de eventos a 3 años.
(SAPPHIRE)
Angioplastia con Stent y Protección en pacientes de alto
riesgo de endarterectomia
N= 334 ptes
Lesiones>50% sintomáticos
Lesiones>80% Asintomáticos



Asintomáticos con estenosis carotidea 70%.
Sintomáticos con estenosis carotidea 30%.
Ptes
de
alto
riesgo:
insuficiencia
cardíaca,
endarterectomía previa con reestenosis, terapia de
radiación previa o cirugía de cuello, mayores de 80
años, angina de pecho, baja F Eyección, indicación de
revasc coronaria.
SAPPHIRE:
Primary end point*
Event
Stent
(n=167)
Endarterectomy
(n=167)
P
for non
inferioriy
p
for
superioriy
Primary
end point
(%)
12.2
20.1
0.004
0.05
*Stroke, death, or MI .
2 Years
end point 40% lower.
Yadav JS et al. N Engl J Med 2004; 351:1493-1501.
CONCLUSIONES
SAPPHIRE:
-
-
No hubo diferencia significativa entre ambos grupos con
respecto al riesgo de stroke u otro evento mayor a tres años.
La tasa del punto primario final
(muerte, ACV o infarto de miocardio dentro de 30 días)
fue 39% menor entre los pacientes que fueron a stent carotídeo
con protección cerebral
Metanálisis

SAPPHIRE, CAVATAS, WALLSTENT
Morbimortalidad
Angioplstia es de 9,3%
Endarterectomía 9%
Diferencia no significativa
EVA-3S:
• n=527 (262 endart, 267 stent)
• Enf carotídea 60% Sintomático
Objetivo: punto primario evaluar incidencia de
stroke y muerte periprocedimiento y a 30 días
post procedimiento.
Punto secundario combinó la evaluación de
stroke periprocedimiento o muerte y stroke
ipsilateral a 4 años de seguimiento.
Resultados: EVA 3S
•
la incidencia de stroke o muerte periprocedimineto y
stroke ipsilateral a 4 años fue mayor para el grupo de
stenting carotideo que con la endarterectomia
• (11·1% vs 6·2%, hazard ratio [HR] 1·97, 95% CI 1·06—3·67; p=0·03).
• La mayor incidencia de stroke o muerte
periprocedimiento y a 30 días post procedimiento.
•
fue
En el seguimiento a 4 años la incidencia de stroke
ipsilateral fue similar para ambos grupos. Stroke o muerte
periprocedimiento HR 1·77 (1·03—3·02; p=0·04, cualquier stroke o muerte
HR 1·39 (0·96—2·00; p=0·08).
published in the October 19, 2006 issue of the New
England Journal of Medicine
SPACE Y EVA-3S

Ninguno de los dos estudios incluyó ptes de alto riesgo o
asintomáticos.

Eva-3S el 92% usó protección cerebral, en SPACE sólo el
27% usó protección cerebral.

La experiencia del operador en el EVA 3S, solo requería un
médico con al menos 5 procedimientos previos (implante de
stent) para participar en el estudio o ningún procedimiento
pero bajo la dirección de algún tutor.
Eva 3
Carotid artery stenting compared with endarterectomy in
patients with symptomatic carotid stenosis (International
Carotid Stenting Study): an interim analysis of a randomised
controlled trial Lancet 2010; 375: 985–97
Published Online
February 26, 2010
International Carotid Stenting Study investigators*
We compared the safety of carotid artery stenting vs endarterectomy.
Methods The International Carotid Stenting Study (ICSS) is a multicentre, international, randomised controlled trial
with blinded adjudication of outcomes. Patients with recently symptomatic carotid artery stenosis were randomly
The primary outcome
measure of the trial is the 3-year rate of fatal or disabling stroke in any territory,
which has not been analysed yet. The
main outcome measure for the interim safety analysis was the 120-day rate of stroke, death, or procedural myocardial
infarction.
Findings The trial enrolled
1713 patients (stenting group, n=855; endarterectomy group, n=858).
The incidence (120 day) of stroke,
death, or procedural myocardial infarction was 8·5% in the
stenting group compared with 5·2% in the endarterectomy group (72 vs 44 events; HR 1·69,
1·16–2·45, p=0·006). Risks of any stroke (65 vs 35 events; HR 1·92, 1·27–2·89) and all-cause death (19 vs seven
events; HR 2·76, 1·16–6·56) were higher in the stenting group than in the endarterectomy group. T hree
procedural myocardial infarctions were recorded in the stenting group, all of which were fatal, compared with
four, all non-fatal, in the endarterectomy group. There was one event of cranial nerve palsy in the stenting group
compared with 45 in the endarterectomy group. There were also fewer haematomas of any severity in the stenting
group than in the endarterectomy group (31 vs 50 events; p=0·0197).
Interpretation Completion of long-term follow-up is needed to establish the effi cacy of carotid artery stenting compared
with endarterectomy. In the meantime, carotid endarterectomy should remain the treatment of choice for patients
Carotid artery stenting compared with endarterectomy in
patients with symptomatic carotid stenosis (International
Carotid Stenting Study): an interim analysis of a randomised
controlled trial Lancet 2010; 375: 985–97
Published Online
February 26, 2010
International Carotid Stenting Study investigators*
Summary
Background Stents are an alternative treatment to carotid endarterectomy for symptomatic carotid stenosis, but
previous trials have not established equivalent safety and effi cacy. We compared the safety of carotid artery stenting with
that of carotid endarterectomy.
Methods The International Carotid Stenting Study (ICSS) is a multicentre, international, randomised controlled trial
with blinded adjudication of outcomes. Patients with recently symptomatic carotid artery stenosis were randomly
assigned in a 1:1 ratio to receive carotid artery stenting or carotid endarterectomy. Randomisation was by telephone call
or fax to a central computerised service and was stratifi ed by centre with minimisation for sex, age, contralateral occlusion,
and side of the randomised artery. Patients and investigators were not masked to treatment assignment. Patients were
The primary outcome
measure of the trial is the 3-year rate of fatal or disabling stroke
in any territory, which has not been analysed yet.
followed up by independent clinicians not directly involved in delivering the randomised treatment.
The
main outcome measure for the interim safety analysis was the 120-day rate of stroke, death, or procedural myocardial
infarction. Analysis was by intention to treat (ITT). This study is registered, number ISRCTN25337470.
Findings The trial enrolled 1713 patients (stenting group, n=855; endarterectomy group, n=858). Two patients in the
stenting group and one in the endarterectomy group withdrew immediately after randomisation, and were not included
in the ITT analysis. Between randomisation and 120 days, there were 34 (Kaplan-Meier estimate 4·0%) events of disabling
stroke or death in the stenting group compared with 27 (3·2%) events in the endarterectomy group (hazard ratio [HR]
1·28, 95% CI 0·77–2·11). The incidence of stroke, death, or procedural myocardial infarction was 8·5% in the stenting
group compared with 5·2% in the endarterectomy group (72 vs 44 events; HR 1·69, 1·16–2·45, p=0·006). Risks of any
stroke (65 vs 35 events; HR 1·92, 1·27–2·89) and all-cause death (19 vs seven events; HR 2·76, 1·16–6·56) were higher in
the stenting group than in the endarterectomy group. Three procedural myocardial infarctions were recorded in the
stenting group, all of which were fatal, compared with four, all non-fatal, in the endarterectomy group. There was one
event of cranial nerve palsy in the stenting group compared with 45 in the endarterectomy group. There were also fewer
haematomas of any severity in the stenting group than in the endarterectomy group (31 vs 50 events; p=0·0197).
Interpretation Completion of long-term follow-up is needed to establish the effi cacy of carotid artery stenting compared
with endarterectomy. In the meantime, carotid endarterectomy should remain the treatment of choice for patients
suitable for surgery.
ICSS: 120-day interim safety results
End point
Stenting
group, n (%)
Carotid
endarterectomy
group, n (%)
Hazard ratio
34 (4.0)
27 (3.2)
1.28 (0.77–2.11)
0.34
Stroke, death, or 72 (8.5)
procedural MI
44 (5.2)
1.69 (1.16–2.45)
0.006
Any stroke
65 (7.7)
35 (4.1)
1.92 (1.27–2.89)
0.002
All-cause death
19 (2.3)
7 (0.8)
2.76 (1.16–6.56)
0.017
Disabling stroke
or death
p
(95% CI)
International Carotid Stenting Study investigators. Lancet 2010;
available at: http://www.thelancet.com.
Carotid artery stenting compared with endarterectomy in
patients with symptomatic carotid stenosis (International
Carotid Stenting Study): an interim analysis of a randomised
controlled trial Lancet 2010; 375: 985–97
Published Online
February 26, 2010
International Carotid Stenting Study investigators*
Summary
Background Stents are an alternative treatment to carotid endarterectomy for symptomatic carotid stenosis, but
previous trials have not established equivalent safety and effi cacy. We compared the safety of carotid artery stenting with
that of carotid endarterectomy.
Methods The International Carotid Stenting Study (ICSS) is a multicentre, international, randomised controlled trial
with blinded adjudication of outcomes. Patients with recently symptomatic carotid artery stenosis were randomly
assigned in a 1:1 ratio to receive carotid artery stenting or carotid endarterectomy. Randomisation was by telephone call
or fax to a central computerised service and was stratifi ed by centre with minimisation for sex, age, contralateral occlusion,
and side of the randomised artery. Patients and investigators were not masked to treatment assignment. Patients were
followed up by independent clinicians not directly involved in delivering the randomised treatment. The primary outcome
measure of the trial is the 3-year rate of fatal or disabling stroke in any territory, which has not been analysed yet. The
main outcome measure for the interim safety analysis was the 120-day rate of stroke, death, or procedural myocardial
infarction. Analysis was by intention to treat (ITT). This study is registered, number ISRCTN25337470.
Findings The trial enrolled 1713 patients (stenting group, n=855; endarterectomy group, n=858). Two patients in the
stenting group and one in the endarterectomy group withdrew immediately after randomisation, and were not included
in the ITT analysis. Between randomisation and 120 days, there were 34 (Kaplan-Meier estimate 4·0%) events of disabling
stroke or death in the stenting group compared with 27 (3·2%) events in the endarterectomy group (hazard ratio [HR]
1·28, 95% CI 0·77–2·11). The incidence of stroke, death, or procedural myocardial infarction was 8·5% in the stenting
group compared with 5·2% in the endarterectomy group (72 vs 44 events; HR 1·69, 1·16–2·45, p=0·006). Risks of any
stroke (65 vs 35 events; HR 1·92, 1·27–2·89) and all-cause death (19 vs seven events; HR 2·76, 1·16–6·56) were higher in
the stenting group than in the endarterectomy group. Three procedural myocardial infarctions were recorded in the
stenting group, all of which were fatal, compared with four, all non-fatal, in the endarterectomy group. There was one
event of cranial nerve palsy in the stenting group compared with 45 in the
endarterectomy group. There were also fewer haematomas of any severity in the stenting group than in the endarterectomy group (31 vs 50 events; p=0·0197).
Interpretation Completion of long-term follow-up is needed to establish the effi cacy of carotid artery stenting compared
with endarterectomy. In the meantime, carotid endarterectomy should remain the treatment of choice for patients
suitable for surgery.
Carotid artery stenting compared with endarterectomy in
patients with symptomatic carotid stenosis (International
Carotid Stenting Study): an interim analysis of a randomised
controlled trial Lancet 2010; 375: 985–97
Published Online
February 26, 2010
International Carotid Stenting Study investigators*
Summary
Background Stents are an alternative treatment to carotid endarterectomy for symptomatic carotid stenosis, but
previous trials have not established equivalent safety and effi cacy. We compared the safety of carotid artery stenting with
that of carotid endarterectomy.
Methods The International Carotid Stenting Study (ICSS) is a multicentre, international, randomised controlled trial
with blinded adjudication of outcomes. Patients with recently symptomatic carotid artery stenosis were randomly
assigned in a 1:1 ratio to receive carotid artery stenting or carotid endarterectomy. Randomisation was by telephone call
or fax to a central computerised service and was stratifi ed by centre with minimisation for sex, age, contralateral occlusion,
and side of the randomised artery. Patients and investigators were not masked to treatment assignment. Patients were
followed up by independent clinicians not directly involved in delivering the randomised treatment. The primary outcome
measure of the trial is the 3-year rate of fatal or disabling stroke in any territory, which has not been analysed yet. The
main outcome measure for the interim safety analysis was the 120-day rate of stroke, death, or procedural myocardial
infarction. Analysis was by intention to treat (ITT). This study is registered, number ISRCTN25337470.
Findings The trial enrolled 1713 patients (stenting group, n=855; endarterectomy group, n=858). Two patients in the
stenting group and one in the endarterectomy group withdrew immediately after randomisation, and were not included
in the ITT analysis. Between randomisation and 120 days, there were 34 (Kaplan-Meier estimate 4·0%) events of disabling
stroke or death in the stenting group compared with 27 (3·2%) events in the endarterectomy group (hazard ratio [HR]
1·28, 95% CI 0·77–2·11). The incidence of stroke, death, or procedural myocardial infarction was 8·5% in the stenting
group compared with 5·2% in the endarterectomy group (72 vs 44 events; HR 1·69, 1·16–2·45, p=0·006). Risks of any
stroke (65 vs 35 events; HR 1·92, 1·27–2·89) and all-cause death (19 vs seven events; HR 2·76, 1·16–6·56) were higher in
the stenting group than in the endarterectomy group. Three procedural myocardial infarctions were recorded in the
stenting group, all of which were fatal, compared with four, all non-fatal, in the endarterectomy group. There was one
event of cranial nerve palsy in the stenting group compared with 45 in the endarterectomy group. There were also fewer
haematomas of any severity in the stenting group than in the endarterectomy group (31 vs 50 events; p=0·0197).
Interpretation: Completion of long-term follow-up is needed to establish the efficacy
of carotid artery stenting compared with endarterectomy. In the meantime, carotid
endarterectomy should remain the treatment of choice for patients suitable for
surgery.
CREST
Carotid Revascularization Endarterectomy
Versus Stenting Trial
2502 pacientes
1321 sintomáticos
y
1181 asintomáticos.
117 centros de US y Canadá.
-Estenosis Sintomática >50% por angiografía o >70% por
TAC/RNM.
-Estenosis Asintomáticos con lesión >60% por angiografía, >70%
por ultrasonido y >80% por TAC/RNM.
-Evalua cualquier stroke, muerte o IM, periprocedimiento y
seguimiento de stroke ipsilateral a 4 años.
CREST: Primary, secondary and
safety end points
End point
CAS
CEA Hazard ratio
(95%CI)
p
Primary end point <4 y
Primary end point: Periprocedural components
Periprocedural stroke and MI
Any periprocedural stroke
Periprocedural major stroke
Periprocedural MI
Cranial nerve palsies
Ipsilateral stroke after
periprocedural period <4 y
7.2
5.2
6.8
4.5
1.11 (0.81–1.51)
1.18 (0.82–1.68)
0.51
0.38
4.1
0.9
1.1
0.3
2.0
2.3
0.7
2.3
4.8
2.4
1.79
1.35
0.50
0.07
0.94
0.01
0.52
0.03
0.0001
0.85
CAS=carotid artery stenting
CEA=carotid endarterectomy
Brott TG et al. American Stroke Association International Stroke
Conference 2010; February 26, 2010; San Antonio, TX.
(1.14–2.82)
(0.54–3.36)
(0.26–0.94)
(0.02–0.18)
(0.50–1.76)
CREST
Conclusión:

No hubo diferencias significativas al comprarar
stroke, muerte, IM, periprocedimiento o stroke
ipsilateral al seguimiento en ninguno de los dos
grupos.

A 30 días el riesgo de stroke fue mayor con
stent pero el IM, fue menor en este grupo con
una diferencia significativa.
TRATAMIENTO ENDOVASCULAR
ANGIOPLASTIA CAROTÍDEA
CONSENSO ESTENOSIS CAROTIDEA
Clase I (nivel de evidencia A)

Estenosis carotídea sintomática (ECS) ≥ 50% (altamente
recomendado ≥ 70%) en pacientes con alto riesgo
quirúrgico.
Clase II (nivel de evidencia A)






ECS ≥ 50% (altamente recomendado ≥ 70%) asociada
con alguna de las siguientes condiciones:
Estenosis posradiación.
Reestenosis de una endarterectomía.
Estenosis severa en tándem.
Estenosis proximal o distal a la bifurcación.
Angioplastia carotídea con protección cerebral en paciente
asintomático con estenosis ≥ 80%, que cumpla con lo
antes mencionado.
Sociedad Argentina de Cardiología
Sociedad Neurológica Argentina
Filial de la Federación Mundial de Neurología

CRM vs ATC

Conarec CRM 11.7% mortalidad- vs EEUU 1%
ESMUSICA 6%
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Endarterectomia vs. Angioplstia Carotídea
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Endarterectomia en Argentina ????
Manos de Expertos
La Angioplastia carotidea es una excelente opción terapéutica
Muchas Gracias!!

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