eMedicine Specialties > Vascular Surgery > Medical Topics

Atherosclerotic Disease of the Carotid Artery: Follow-up

Author: Niten Singh, MD, Assistant Professor of Surgery, Uniformed Services University of the Health Sciences; Chief of Endovascular Surgery, Madigan Army Medical Center
Coauthor(s): Sean D O'Donnell, MD, Director, Department of Surgery, Section of Vascular and Endovascular Surgery, Washington Hospital Center; David L Gillespie, MD, FACS, RVT, DMCC, COL, MC, USA Chief and Program Director, Vascular Surgery Service, Walter Reed Army Medical Center; Professor of Surgery, Uniformed Services University of the Health Sciences; Vascular Surgery Consultant, Office of the US Army Surgeon General; James M Goff, MD, Assistant Chief, Department of Surgery, Walter Reed Army Medical Center; Assistant Professor, F Department of Surgery, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences
Contributor Information and Disclosures

Updated: Jan 8, 2009

Outcome and Prognosis

  • Cranial nerve injuries occur in 2-7% of patients. Recurrent laryngeal and hypoglossal nerve dysfunctions are the most common.
  • Postoperative stroke occurs in 1-5% of patients.1
  • The perioperative mortality rate is 0.5-1.8%.
  • Recurrent stenosis occurs in 1-20% of cases, and reoperation is necessary in 1-3% of cases.
  • Following a successful carotid endarterectomy, the 2-year stroke risk in the NASCET was 1.6%, compared with 12.2% for the medically managed patients.1
  • In the NASCET, the cumulative risk of an ipsilateral stroke was 9% for the surgical patients and 26% for the medically managed patients.1
  • In the Asymptomatic Carotid Atherosclerosis Study (ACAS), the 5-year risk for ipsilateral stroke was 5.1% for the surgical group compared with 11% for the medical group. The stroke risk of arteriography was attributed to the surgical group and was 1.2%.6
  • In the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial, carotid stenting was found to not be inferior to carotid endarterectomy in patients with severe stenosis and coexisting conditions.
  • Recent meta-analysis revealed that protected (use of embolic protection wire) carotid angioplasty and stenting was associated with a 30-day stroke and death rate of 2.4%.7

Future and Controversies

Carotid angioplasty and stenting research will continue to evolve, and studies are underway to evaluate its role in asymptomatic patients with high grade stenosis.

As industry and interest from numerous specialties continues in carotid angioplasty and stenting, the devices available will continue to evolve.

 


More on Atherosclerotic Disease of the Carotid Artery

Overview: Atherosclerotic Disease of the Carotid Artery
Workup: Atherosclerotic Disease of the Carotid Artery
Treatment: Atherosclerotic Disease of the Carotid Artery
Follow-up: Atherosclerotic Disease of the Carotid Artery
Multimedia: Atherosclerotic Disease of the Carotid Artery
References
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References

  1. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. Aug 15 1991;325(7):445-53. [Medline].

  2. Canadian Cooperative Study Group. A randomized trial of aspirin and sulfinpyrazone in threatened stroke. The Canadian Cooperative Study Group. N Engl J Med. Jul 13 1978;299(2):53-9. [Medline].

  3. Halliday A, Mansfield A, Marro J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. May 8 2004;363(9420):1491-502. [Medline].

  4. Mas JL, Trinquart L, Leys D, et al. Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial. Lancet Neurol. Oct 2008;7(10):885-92. [Medline].

  5. Centers for Medicare and Medicaid Services. Available at www.cms.hhs.gov.

  6. Young B, Moore WS, Robertson JT, et al. An analysis of perioperative surgical mortality and morbidity in the asymptomatic carotid atherosclerosis study. ACAS Investigators. Asymptomatic Carotid Artheriosclerosis Study. Stroke. Dec 1996;27(12):2216-24. [Medline].

  7. Wiesmann M, Schopf V, Jansen O, et al. Stent-protected angioplasty versus carotid endarterectomy in patients with carotid artery stenosis: meta-analysis of randomized trial data. Eur Radiol. Dec 2008;18(12):2956-66. [Medline].

  8. Barnett HJ, Taylor DW, Eliasziw M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. Nov 12 1998;339(20):1415-25. [Medline].

  9. Burton KR, Lindsay TF. Assessment of short-term outcomes for protected carotid angioplasty with stents using recent evidence. J Vasc Surg. Dec 2005;42(6):1094-100. [Medline].

  10. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet. Jun 2 2001;357(9270):1729-37. [Medline].

  11. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA. May 10 1995;273(18):1421-8. [Medline].

  12. Friedman SG. A History of Vascular Surgery. Mount Kisco, NY: Futura Publishing Co; 1989.

  13. Gurm HS, Yadav JS, Fayad P, et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med. Apr 10 2008;358(15):1572-9. [Medline].

  14. Hobson RW 2nd. Status of carotid angioplasty and stenting trials. J Vasc Surg. Apr 1998;27(4):791. [Medline].

  15. Hobson RW 2nd, Goldstein JE, Jamil Z, et al. Carotid restenosis: operative and endovascular management. J Vasc Surg. Feb 1999;29(2):228-35; discussion 235-8. [Medline].

  16. Inzitari D, Eliasziw M, Gates P, et al. The causes and risk of stroke in patients with asymptomatic internal-carotid-artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. Jun 8 2000;342(23):1693-700. [Medline].

  17. Jackson MR, Chang AS, Robles HA, et al. Determination of 60% or greater carotid stenosis: a prospective comparison of magnetic resonance angiography and duplex ultrasound with conventional angiography. Ann Vasc Surg. May 1998;12(3):236-43. [Medline].

  18. Liapis C, Kakisis J, Papavassiliou V, et al. Hemostatic function and carotid artery disease. Int Angiol. Mar 2004;23(1):14-7. [Medline].

  19. Moore WS. Fundamental Considerations in Cerebrovascular Disease. In: Rutherford Vascular Surgery. 5th ed. Philadelphia, Pa: WB Saunders; 2000:1713-30.

  20. [Best Evidence] Ringleb PA, Allenberg J, Bruckmann H, et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet. Oct 7 2006;368(9543):1239-47. [Medline].

  21. Wakhloo AK, Lieber BB, Seong J, et al. Hemodynamics of carotid artery atherosclerotic occlusive disease. J Vasc Interv Radiol. Jan 2004;15(1 Pt 2):S111-21. [Medline].

  22. Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. Oct 7 2004;351(15):1493-501. [Medline].

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Further Reading

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Keywords

atherosclerotic disease of the carotid artery, carotid artery, atherosclerosis, stroke, transient ischemic attacks, TIAs, cerebral infarction, cerebral intermittent claudication, extracranial carotid disease, carotid plaque, angioplasty, endarterectomy, hypertension, carotid bruit, diabetes, smoking, atrial fibrillation, obesity, hyperlipidemia, homocysteine, embolization, artery blockage, artery

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Contributor Information and Disclosures

Author

Niten Singh, MD, Assistant Professor of Surgery, Uniformed Services University of the Health Sciences; Chief of Endovascular Surgery, Madigan Army Medical Center
Niten Singh, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Sean D O'Donnell, MD, Director, Department of Surgery, Section of Vascular and Endovascular Surgery, Washington Hospital Center
Sean D O'Donnell, MD is a member of the following medical societies: American College of Surgeons and Association of Military Surgeons of the US
Disclosure: Nothing to disclose.

David L Gillespie, MD, FACS, RVT, DMCC, COL, MC, USA Chief and Program Director, Vascular Surgery Service, Walter Reed Army Medical Center; Professor of Surgery, Uniformed Services University of the Health Sciences; Vascular Surgery Consultant, Office of the US Army Surgeon General
David L Gillespie, MD, FACS, RVT, DMCC, COL, MC is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Venous Forum, Eastern Vascular Society, Society for Vascular Surgery, and Southern Association for Vascular Surgery
Disclosure: Nothing to disclose.

James M Goff, MD, Assistant Chief, Department of Surgery, Walter Reed Army Medical Center; Assistant Professor, F Department of Surgery, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences
James M Goff, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Richard M Stillman, MD, FACS, Honorary Medical Staff, Northwest Medical Center; Former Chief of Staff and Medical Director, Wound Healing Center, Department of Surgery, Northwest Medical Center
Richard M Stillman, MD, FACS is a member of the following medical societies: American College of Angiology, American College of Surgeons, Association for Academic Surgery, and Society of University Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Vincent Lopez Rowe, MD, Assistant Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center
Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, Association for Academic Surgery, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

 
 
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