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Atherosclerotic Disease of the Carotid Artery Treatment & Management

  • Author: April L Rodriguez, MD, MS; Chief Editor: Vincent Lopez Rowe, MD  more...
 
Updated: Apr 08, 2016
 

Risk Factor Modification

Lifestyle or medical interventions are implemented in order to address the following risk factors:

  • Hypertension
  • Hypercholesterolemia
  • Smoking 
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Pharmacologic Therapy

Aspirin (30-1350 mg/day) irreversibly acetylates the cyclooxygenase of platelets, thus inhibiting platelet synthesis of thromboxane A2. Prostacyclin production in the endothelium is reduced, but this effect is reversible and short-lived. A reduction in transient ischemic attacks (TIAs), stroke, and death in men was shown in the Canadian Cooperative Study Group.[13]

Ticlopidine (250 mg q12hr) is a thienopyridine that irreversibly alters the platelet membrane and inhibits platelet aggregation. It is approximately 10% more effective than aspirin. Toxicity includes neutropenia and diarrhea. Clopidogrel (75 mg/day) is similar to ticlopidine; the risk of neutropenia is low.

Warfarin (titrated international normalized ratio [INR] 2-3) use in patients with noncardiac emboli is controversial.

Antiplatelet therapy (cilostazol) may reduce the progression of carotid artery stenosis after stent implantation.[14]

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Carotid Endarterectomy

The following are indications for carotid endarterectomy (CEA), based on prospective randomized trials:

  • Symptomatic patients with greater than 70% stenosis - Clear benefit was found in the North American Symptomatic Carotid Endarterectomy Trial (NASCET); the incidence of ipsilateral stroke in 2 years was 9% with surgery and 26% with medical management [1]
  • Symptomatic patients with greater than 50-69% stenosis - Benefit is marginal and appears to be greater for male patients
  • Asymptomatic patients with greater than 60% stenosis - Benefit is significantly less than for symptomatic patients with greater than 70% stenosis
  • Available literature includes considerable overlap in the percent of stenosis used as the threshold for CEA; in general, symptomatic patients with greater than 50% stenosis and healthy, asymptomatic patients with greater than 60% stenosis warrant consideration for CEA
  • Symptomatic trials include patients with transient ischemic attacks (TIAs) or minor strokes within 3 months of entry

Contraindications for CEA include the following:

  • Patients with a severe neurologic deficit after a cerebral infarction
  • Patients with an occluded carotid artery
  • Concurrent medical illness that would significantly limit the patient’s life expectancy

For the indications listed above, medical management was found to be inferior to CEA.

Cardiac evaluation

Patients with carotid artery stenosis have a high incidence of concomitant coronary artery disease (CAD). American Heart Association (AHA) recommendations regarding cardiac evaluation for noncardiac surgery should therefore be adhered to. In brief, the AHA recommends a functional assessment be performed on all patients with a history of new-onset angina and new symptoms following coronary angioplasty or bypass.

Nondiabetic patients younger than 70 years with no cardiac symptoms and normal findings on electrocardiography (ECG) may undergo CEA without further cardiac workup.

Preoperative imaging studies

Imaging studies should be performed preoperatively used to determine the extent of stenosis and to evaluate for kinks and coils that may affect the conduct of the operation (see Workup). Many surgeons who work with certified laboratories proceed with surgery on the basis of carotid duplex ultrasonography alone. If any doubt exists regarding the degree of stenosis or the distal extent of the disease, arteriography of the arch and the carotid is indicated.

The extent of the disease should also be noted, with particular attention to the superior extent of the stenosis. The superior disease extent may influence the type of anesthesia chosen, and additional measures may prove necessary to expose an unusually high lesion.

Anatomic considerations

Anatomic issues that would be unfavorable for CEA include the following:

  • Lesions that extend above C2
  • Prior irradiation of the neck
  • Prior neck operation

Anesthesia

Local anesthesia has the advantage of allowing direct evaluation of the patient’s neurologic status without sophisticated monitoring. This enables the surgeon to operate on most patients without the need for a shunt, which is a technical nuisance and may pose an increased risk of stroke to the patient.

General anesthesia has the advantage of improved airway control and patient comfort during prolonged operations. However, it does require the use of routine or selected shunting, and selective shunting requires the use of electroencephalography (EEG), stump pressures, and transcranial Doppler or some other form of cerebral monitoring to assess the need for a shunt.

Procedure

A vertical incision is made along the anterior border of the sternocleidomastoid. An oblique incision is made in the skin fold over the carotid bifurcation. (See the image below.)

Carotid artery exposed prior to carotid endarterec Carotid artery exposed prior to carotid endarterectomy (coil present in internal carotid artery).

The endarterectomy is carried out in a smooth plane in the media of the artery. The most important aspect of this portion of the procedure is to obtain a smooth, tapering endpoint on the internal carotid (see the image below). Occasionally, tacking sutures are required to accomplish this.

Carotid artery following endarterectomy and prior Carotid artery following endarterectomy and prior to closure (tapered endpoint and smooth appearance of lumen).

The endarterectomy is closed either primarily or with a patch (see the image below). The technical result should be verified by means of completion angiography or duplex ultrasonography.

Carotid artery following Dacron patch angioplasty. Carotid artery following Dacron patch angioplasty.

Postoperative care

Postoperatively, a complete blood count is obtained, electrolyte concentrations assessed, and ECG performed. Hemodynamic monitoring is instituted, with a focus on maintaining the patient’s blood pressure at its preoperative range. The patient is observed for the formation of a hematoma that may compromise the airway. Antiplatelet therapy is necessary.

Patients are evaluated 2 weeks postoperatively for wound or neurologic complications. Carotid duplex ultrasonography is performed after 6 months and annually thereafter.

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Carotid Angioplasty and Stenting

Carotid angioplasty and stenting (CAS) has emerged as a viable option in the treatment of carotid artery stenosis. Rapid growth and technologic advancements have allowed this procedure to become a treatment strategy, particularly in high-risk patients. Most of the trials published to date have shown varying results with CAS. Many are industry-sponsored, and some have different patient populations (eg, symptomatic and asymptomatic patients). Further randomized prospective studies are needed before any conclusion can be made.

Despite advances in CAS, CEA remains the standard of care. Currently, the Centers for Medicare and Medicaid Services (CMS) have approved reimbursement for CAS only in the following patients[15] :

  • Symptomatic patients with a high-grade stenosis (>70%) who are considered to be at high risk for CEA
  • Patients who are at high risk for CEA and have asymptomatic carotid stenosis greater than 80%

Anatomic considerations

The following factors are considered to increase the risk of CAS and should be taken into account in procedural planning[16] :

  • "Soft" lipid-rich plaque identified on noninvasive imaging
  • Extensive (≥15 mm) disease
  • Preocclusive lesion
  • Circumferential heavy calcification 
  • Aortoiliac tortuosity
  • Type III aortic arch
  • Carotid lesion with more than two 90º bends within a short distance of the target lesion
  • Significant tortuosity of the distal internal carotid artery
  • Severe aortic arch atherosclerosis

In a study aimed at identifying angiographic features that would account for the difference in periprocedural stroke and death rates between CAS and CEA, the higher stroke and death rate in patients who underwent CAS was found to be associated with a longer lesion length (≥12.85 mm),  sequential lesions, or remote lesions extending beyond the bulb.[17]

Procedure

The procedure is performed either in an operating room with C-arm capabilities or in an angiographic suite. Local anesthesia with limited sedation is used so that the patient’s neurologic status can be constantly monitored.

Femoral artery access is achieved and an arch arteriogram performed. The affected side is cannulated, and selective carotid arteriograms are then performed (see the images below).

Selective left carotid angiogram. Selective left carotid angiogram.
Oblique view of left carotid artery demonstrating Oblique view of left carotid artery demonstrating lesion within internal carotid artery.

Next, a long sheath is placed over a wire into the common carotid artery, and a 0.014-in. filter wire is placed into the internal carotid distal to the lesion to provide embolic protection. After appropriate sizing, the lesion is quickly predilated with a small balloon. The stent is then placed and postdilated with a larger balloon. (See the images below.)

Placement of stent into internal carotid artery. N Placement of stent into internal carotid artery. Note filter wire in upper photos (dots at top of internal carotid artery).
Angioplasty after stent placement; again, note fil Angioplasty after stent placement; again, note filter wire protecting distal carotid artery.

Next, a completion arteriogram is performed to confirm that the lesion has been treated and that no other abnormalities exist within the internal carotid or cerebral views (see the image below). The procedure is completed, and the access site in the femoral artery is typically closed with a closure device. The patient is usually monitored overnight and discharged the next day.

Completion arteriogram displaying improvement in d Completion arteriogram displaying improvement in diameter of internal carotid artery.
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Complications

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 is 0.5-1.8%. Recurrent stenosis occurs in 1-20% of cases, and reoperation is necessary in 1-3% of cases.

In the CREST data, the rate of restenosis or occlusion at 2 years was approximately 6%, and there was no difference between CAS and CEA.[18] Secondary analysis of the CREST data sought to identify predictors of restenosis or occlusion. Female sex, diabetes and dyslipidemia were independent predictors of restenosis or occlusion at 2 years after either CEA or CAS. Smoking was also found to be an independent predictor; however, this was only noted in patients who had undergone CEA.

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Contributor Information and Disclosures
Author

April L Rodriguez, MD, MS Senior Resident, Integrated Vascular Surgery Residency, Department of Surgery, University of Washington School of Medicine

April L Rodriguez, MD, MS is a member of the following medical societies: American College of Surgeons, Society for Clinical Vascular Surgery, Vascular and Endovascular Surgery Society

Disclosure: Nothing to disclose.

Coauthor(s)

Niten Singh, MD, FACS Associate Professor of Surgery, University of Washington School of Medicine; Director of Vascular Limb Preservation, Vascular Surgery Clinic at Harborview

Niten Singh, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Society for Vascular Surgery

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

Acknowledgements

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.

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.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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. 1991 Aug 15. 325(7):445-53. [Medline].

  2. 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. 1996 Dec. 27(12):2216-24. [Medline].

  3. 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. 2008 Oct. 7(10):885-92. [Medline].

  4. 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. 2008 Dec. 18(12):2956-66. [Medline].

  5. Meier P, Knapp G, Tamhane U, Chaturvedi S, Gurm HS. Short term and intermediate term comparison of endarterectomy versus stenting for carotid artery stenosis: systematic review and meta-analysis of randomised controlled clinical trials. BMJ. 2010 Feb 12. 340:c467. [Medline]. [Full Text].

  6. 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. 2004 May 8. 363(9420):1491-502. [Medline].

  7. Illuminati G, Ricco JB, Caliò F, et al. Short-term results of a randomized trial examining timing of carotid endarterectomy in patients with severe asymptomatic unilateral carotid stenosis undergoing coronary artery bypass grafting. J Vasc Surg. 2011 Oct. 54(4):993-9. [Medline].

  8. Brown K, Itum DS, Preiss J, Duwayri Y, Veeraswamy RK, Salam A, et al. Carotid artery stenting has increased risk of external carotid artery occlusion compared with carotid endarterectomy. J Vasc Surg. 2014 Jul 23. [Medline].

  9. Brott TG, Hobson RW 2nd, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010 Jul 1. 363(1):11-23. [Medline]. [Full Text].

  10. Hill MD, Brooks W, Mackey A, Clark WM, Meschia JF, Morrish WF, et al. Stroke after carotid stenting and endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Circulation. 2012 Dec 18. 126 (25):3054-61. [Medline].

  11. Hye RJ, Mackey A, Hill MD, Voeks JH, Cohen DJ, Wang K, et al. Incidence, outcomes, and effect on quality of life of cranial nerve injury in the Carotid Revascularization Endarterectomy versus Stenting Trial. J Vasc Surg. 2015 May. 61 (5):1208-14. [Medline].

  12. van Engelen A, Wannarong T, Parraga G, Niessen WJ, Fenster A, Spence JD, et al. Three-Dimensional Carotid Ultrasound Plaque Texture Predicts Vascular Events. Stroke. 2014 Jul 17. [Medline].

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

  14. Kato T, Sakai H, Takagi T, Nishimura Y. Cilostazol Prevents Progression of Asymptomatic Carotid Artery Stenosis in Patients with Contralateral Carotid Artery Stenting. AJNR Am J Neuroradiol. 2012 Mar 1. [Medline].

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

  16. [Guideline] Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK, et al. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011 Sep. 54 (3):e1-31. [Medline].

  17. Moore WS, Popma JJ, Roubin GS, Voeks JH, Cutlip DE, Jones M, et al. Carotid angiographic characteristics in the CREST trial were major contributors to periprocedural stroke and death differences between carotid artery stenting and carotid endarterectomy. J Vasc Surg. 2016 Apr. 63 (4):851-858.e1. [Medline].

  18. Lal BK, Beach KW, Roubin GS, Lutsep HL, Moore WS, Malas MB, et al. Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial. Lancet Neurol. 2012 Sep. 11 (9):755-63. [Medline].

 
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Arteriogram of aortic arch and its branches.
Arteriogram of carotid stenosis.
Atherosclerotic plaque removed at time of carotid endarterectomy (areas of ulceration with thrombus and intraplaque hemorrhage are present).
Carotid artery exposed prior to carotid endarterectomy (coil present in internal carotid artery).
Carotid artery following endarterectomy and prior to closure (tapered endpoint and smooth appearance of lumen).
Carotid artery following Dacron patch angioplasty.
Selective left carotid angiogram.
Oblique view of left carotid artery demonstrating lesion within internal carotid artery.
Placement of stent into internal carotid artery. Note filter wire in upper photos (dots at top of internal carotid artery).
Angioplasty after stent placement; again, note filter wire protecting distal carotid artery.
Completion arteriogram displaying improvement in diameter of internal carotid artery.
Normal carotid arteries on color flow duplex ultrasonography.
Color flow duplex ultrasonogram reveals 80-99% left carotid stenosis and normal right carotid.
Carotid plaque.
 
 
 
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