Atherosclerotic Disease of the Carotid Artery Treatment & Management

  • Author: Niten Singh, MD; Chief Editor: Vincent Lopez Rowe, MD   more...
 
Updated: Oct 14, 2011
 

Medical Therapy

  • Antiplatelet agents
    • Aspirin (30–1350 mg qd) 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 TIAs, stroke, and death in men was shown in the Canadian Cooperative Study Group.[2]
    • Ticlopidine (250 mg bid) 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 qd) is similar to ticlopidine; risk of neutropenia is low.
  • Anticoagulation: Warfarin (titrated international normalized ratio [INR] 2–3) use in patients with noncardiac emboli is controversial.
  • Of the indications listed above (see Indications section), medical management was found to be inferior to carotid endarterectomy.
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Surgical Therapy

Endovascular therapy

  • 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.
    • Numerous studies, including the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial, have found that CAS is not inferior to carotid endarterectomy (CEA) at one year. Published long-term results show no significant difference between groups in the prespecified secondary endpoint trial, a composite at 3 years of death, stroke, or myocardial infarction (MI) within 30 days of the procedure (or death or ipsilateral stroke between 31 and 1080 days).[3]
    • The endarterectomy versus stenting in patients with symptomatic severe carotid stenosis (EVA-3S) trial revealed a higher stroke and death rate in CAS; however, cerebral protection was not uniformly used and dual antiplatelet therapy was not initiated on all patients.[4]
    • Another study evaluated the outcomes of 2502 patients with symptomatic or asymptomatic carotid stenosis after undergoing carotid-artery stenting or carotid endarterectomy. The study found that the risk of stroke, myocardial infarction, or death was similar with both procedures. However, a higher risk of stroke was found with the stenting technique and a higher risk of myocardial infarction was found with the endarterectomy technique.[5]
    • Most of the trials (see the Reference section) have shown varying results with CAS. Many are industry sponsored and some have different patient populations (ie, symptomatic and asymptomatic patients). Further randomized prospective studies are needed before any conclusion can be made. Despite advances in carotid artery stenting, carotid endarterectomy remains the current standard of care.
    • Currently, the Centers for Medicare and Medicaid Services (CMS) have approved reimbursement for CAS only in symptomatic patients with a high-grade stenosis (>70%) who are deemed high risk for CEA, and those patients who are at high risk for CEA and have asymptomatic carotid stenosis greater than 80%.[6]
  • Procedural details
    • The procedure is performed in either an operating room with C-arm capabilities or an angiographic suite.
    • Local anesthesia with limited sedation is used so that the patient's neurologic status can constantly be monitored.
    • Femoral artery access is achieved and an arch arteriogram performed. The affected side is cannulated and selective carotid arteriograms are then performed. Next, a long sheath is placed over a wire into the common carotid artery and a 0.014 inch filter wire is placed into the internal carotid distal to the lesion to provide for embolic protection. Next, after appropriate sizing, the lesion is predilated quickly with a small balloon. The stent is then placed and postdilated with a larger balloon. A completion arteriogram is than performed to ensure that the lesion has been treated and that no other abnormalities exist within the internal carotid or cerebral views. 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.
  • Carotid endarterectomy
    • To evaluate the relative short-term safety and intermediate-term efficacy of carotid endarterectomy versus carotid artery stenting, Meier et al conducted a systematic review and meta-analysis of 11 randomized controlled clinical trials.[7] Carotid endarterectomy carried a lower risk of periprocedural mortality or stroke than did carotid stenting (odds ratio [OR], 0.67; 95% confidence interval [CI], 0.47-0.95; P=0.025), mainly because of a decreased risk of stroke (0.65, 0.43 to 1.00; P=0.049).
    • However, the risk of death (OR, 1.14; CI, 0.56-2.31; P=0.727) and the composite end point mortality or disabling stroke (OR, 0.74; CI, 0.53-1.05; P=0.088) did not differ significantly between the two procedures. The odds of periprocedural myocardial infarction (OR, 2.69; CI, 1.06-6.79; P=0.036) or cranial nerve injury (OR, 10.2; CI, 4.0-26.1; P< 0.001) were higher with the carotid endarterectomy group than with the carotid stenting group. In the intermediate term, the risk of stroke or death did not differ significantly with the two treatments (hazard ratio, 0.90; 95% CI, 0.74-1.1; P=0.314).
    • Another study suggested that with regard to timing of carotid endarterectomy, previous or simultaneous carotid endarterectomy in patients with unilateral severe asymptomatic carotid stenosis (>70%) undergoing a coronary artery bypass graft can better prevent stroke than delayed carotid endarterectomy. The overall surgical risk was not increased.[8]
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Preoperative Details

  • Cardiac evaluation
    • Patients with carotid artery stenosis have a high incidence of concomitant coronary artery disease.
    • Adherence to the American Heart Association's recommendations regarding cardiac evaluation for noncardiac surgery should be followed. In summary, they recommend a functional assessment 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 ECG may undergo carotid endarterectomy without further cardiac workup.
  • Preoperative imaging studies
    • Imaging studies should be used to determine the extent of stenosis and to evaluate for kinks and coils that may affect the conduct of the operation (see Imaging Studies). Many surgeons who work with certified laboratories proceed with surgery based on the carotid duplex alone. If any doubt exists regarding the degree of stenosis or the distal extent of the disease, an arch and carotid arteriogram is performed.
    • The extent of the disease should also be noted, with particular attention to the superior extent of the stenosis. This may impact the type of anesthesia chosen and reveal the need for additional measures to expose an unusually high lesion.
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Intraoperative Details

  • 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, stump pressures, and transcranial Doppler or some other form of cerebral monitoring to assess the need for a shunt.
  • Incision
    • A vertical incision should be made along the anterior border of the sternocleidomastoid muscle.
    • An oblique incision should be made in the skin fold over the carotid bifurcation.
  • Endarterectomy
    • 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. Occasionally, tacking sutures are required to accomplish this.
  • Shunt (see Anesthesia)
  • Closing
    • The endarterectomy is closed either primarily or with a patch.
    • The technical result should be verified by completion angiography or duplex.
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Postoperative Details

  • Obtain CBC count and electrolytes, and perform an ECG.
  • Perform frequent neurologic assessment.
  • Institute hemodynamic monitoring, with focus on maintaining the patient's blood pressure at its preoperative range.
  • Observe the patient for a hematoma that may compromise the airway.
  • Antiplatelet therapy is necessary.
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Follow-up

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Complications

  • Cardiac ischemia
  • Cranial nerve injury
  • Hematoma with or without airway compromise
  • Hypertension and hypotension
  • Perioperative stroke
  • Recurrent stenosis
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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%.[9]
  • 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%.[10]
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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.

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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.

Specialty Editor Board

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.

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

Vincent Lopez Rowe, MD  Associate 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, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

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

Vincent Lopez Rowe, MD  Associate 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, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

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

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

  7. [Best Evidence] 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. Feb 12 2010;340:c467. [Medline].

  8. 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. Oct 2011;54(4):993-9. [Medline].

  9. 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].

  10. 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].

  11. 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].

  12. 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].

  13. 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].

  14. 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].

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

  16. 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].

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

  18. 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].

  19. 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].

  20. 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].

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

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

  23. [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].

  24. 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].

  25. 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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Arteriogram of the aortic arch and its branches.
Arteriogram of a carotid stenosis.
Atherosclerotic plaque removed at the time of carotid endarterectomy (areas of ulceration with thrombus and intraplaque hemorrhage present).
Carotid artery exposed prior to carotid endarterectomy (coil present in the internal carotid artery).
Carotid artery following endarterectomy and prior to closure (tapered endpoint and smooth appearance of the lumen).
Carotid artery following Dacron patch angioplasty.
Selective left carotid angiogram.
Oblique view of the 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.
Color flow duplex revealing an 80-99% left carotid stenosis and a normal right carotid.
Carotid plaque.
 
 
 
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