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Management of Carotid Stenosis to Prevent Ischemic Stroke |
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Carotid artery stenosis is one of the most
important risk factors for ischemic
stroke. It is imperative to assess the carotid arteries in anyone presenting
with ischemic stroke, as intervention can reduce the future risk of stroke.
Atherosclerosis most commonly affects the carotid bifurcation or proximal
internal carotid artery. The carotid arteries can be well visualized by doppler/ultrasound
and magnetic resonance angiography, as well as by
conventional angiography. |
Epidemiology
Approximately 10% of ischemic strokes are due to carotid stenosis.
Pathophysiology
Stroke may occur due to carotid artery stenosis in several ways:
• Unstable atheromatous
plaque in the carotid artery may rupture and result in thrombosis, thus
occluding the lumen of the vessel. A stroke will then ensue secondary to lack of
blood flow to the corresponding area of brain the carotid artery supplies.
• An unstable plaque in
the carotid artery may rupture and embolize distally to affect a branch of the
carotid artery, most often the middle cerebral artery (i.e.,
artery to artery embolism).
• In a patient with a
critical stenosis (near occlusion), any drop in systemic blood pressure may
result in hypoperfusion across the already compromised carotid artery resulting
in a
“watershed” territory stroke. |
Management
The definitive management for patients with
symptomatic severe carotid stenosis is carotid endarterectomy.
“Severe” stenosis is defined as greater than 70% stenosis of the carotid artery.
The designation of “symptomatic stenosis” requires that a patient has a stroke
or TIA ipsilateral to the side of
carotid stenosis. In these patients with symptomatic stenosis of greater 70%,
the North American Symptomatic Carotid Endarterectomy Trial (NASCET)
demonstrated a highly significant reduction of future stroke risk. In patients
with symptomatic carotid stenosis of 50-69%, the benefits were still present but
not as profound. In practice, in a patient with moderate symptomatic carotid
stenosis, the risks and benefits need to be weighed based on the patient’s other
co-morbidities, and the complication rate of the local surgeons.
If the risk of disabling stroke and death associated with endarterectomy
exceeds 3%, then the benefit of endarterectomy compared to medical therapy is
lost. Carotid endarterectomy should be performed only at institutions and by
surgeons whose patients have low rates of complications. |
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Above: Intraoperative
carotid endarterectomy. |
In addition to surgery, patients with carotid stenosis should be on an
antiplatelet agent such as aspirin or plavix. Additionally, aggressive risk
factor modification should be undertaken including improving cholesterol
profile, smoking cessation and blood pressure control. |
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Above: Kaplan–Meier Curves for Event-free
Survival among Patients with Severe and Moderate Stenosis. The curves show the
probability of avoiding an ipsilateral stroke of any degree of severity
(left-hand panels) and a disabling ipsilateral stroke (right-hand panels) among
patients with carotid stenosis of 70 to 99 percent (top), 50 to 69 percent
(center), and less than 50 percent (bottom) who were randomly assigned to
undergo carotid endarterectomy (surgical-therapy group) or to receive medical
therapy alone (medical-therapy group). Also shown are the P values from the
Mantel–Haenszel chi-square test used to compare the survival curves, with the 95
percent confidence interval (CI) for each curve and the overlap between the
confidence intervals indicated by bands of color. The numbers below the panels
are the numbers of patients in each group who were still at risk during each
year of follow-up. These analyses were conducted according to the
intention-to-treat principle and include patients who crossed over to the other
treatment. The survival curves for medically treated patients differ
significantly among the three severity-of-stenosis groups (P=0.02 for all
ipsilateral strokes and P<0.001 for disabling ipsilateral strokes); the curves
did not differ significantly for surgically treated patients (P=0.58 and P=0.51,
respectively). From Barnett H. et. al. Benefit of Carotid Endarterectomy in
Patients with Symptomatic Moderate or Severe Stenosis. NEJM, 1998; 339:
1415-1425.
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In patients with incidentally discovered “asymptomatic
carotid stenosis,” surgery may be beneficial, but only if the
patient’s surgical risk is low (<3%) and life expectancy is at least 5 years.
The recommendations below are from the AHA guidelines for Carotid Endarterectomy.
Patients With Asymptomatic Carotid Artery Disease
For patients with a surgical risk <3% and life expectancy of at least 5
years:
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Proven indications: Ipsilateral carotid
endarterectomy is acceptable for stenotic lesions ( 60% diameter reduction of
distal outflow tract with or without ulceration and with or without antiplatelet
therapy, irrespective of contralateral artery status, ranging from no disease to
occlusion [Grade A recommendation]).
•
Acceptable indications: Unilateral carotid
endarterectomy simultaneous with coronary artery bypass graft for stenotic
lesions (60% with or without ulcerations with or without antiplatelet therapy
irrespective of contralateral artery status [Grade C recommendation]).
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Uncertain indications: Unilateral carotid
endarterectomy for stenosis >50% with large or complex ulcers irrespective of contralateral
internal carotid artery status (Grade C recommendation).
Adapted from: Biller J, et. al. Guidelines for Carotid Endarterectomy: A
Statement for Healthcare Professionals From a Special Writing Group of the
Stroke Council, American Heart Association. Stroke, Feb 1998; 29: 554 - 562. |
Carotid Stenting
More recently, the use of carotid angioplasty with stenting has come into
practice. It should be noted however that there are not good clinical trials yet
which compare carotid stenting with surgical intervention. Carotid stenting
offers some apparent advantages to surgery in that the perioperative mortality
may be less, especially in patients with many co-morbidities. However, only time
will tell what the true efficacy is based on direct head-to-head comparisons
with carotid endarterectomy. |
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Above: Stenting is performed similar to
angioplasty. A catheter is passed to the area of stenosis and a balloon is
inflated to expand the stent. The balloon is then taken down and the stent
remains. |
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