Carotid Stenosis
- Generally
found in patients after TIA or stroke
- Incidental
cases in angiography for other reasons (primarily preoperative cardiac
bypass patients)
- Carotid
bruit in a symptomatic patient serves only as a marker of generalized
atherosclerotic disease
- 4% of
population >40 years of age have bruits
- Diagnosis:
- Carotid
duplex is minimally invasive screening study
- MRA has
been gaining more popularity as technique has improved
- Cerebral
angiography remains the gold standard
- Treatment:
- Depends
on patient’s symptoms and the degree of stenosis
- Carotid
endarterectomy (CEA) vs. medical therapy (anti-platelet agents,
anticoagulation)
- Symptomatic
carotid stenosis:
- CEA
provides significant protection against subsequent ipsilateral cerebral
ischemia in patients with high grade stenosis, the benefits of which are
realized early and persist over extended periods of time
- NASCET
(North American Symptomatic Carotid Endarterectomy Trial)
- Randomized
controlled clinical trial comparing optimal medical therapy vs. CEA in
symptomatic patients with >70% stenosis
- Risk of
fatal/non-fatal stroke at 24 months was 9% in CEA group vs. 26% in
medical group
- ECST
(European Carotid Surgery Trial)
- Randomized
controlled clinical trial comparing optimal medical therapy vs. CEA in
symptomatic patients with >70% stenosis
- Cumulative
ipsilateral stroke rate over 3 years was 12.3% in CEA group vs. 21.9% in
medical group
- Asymptomatic
carotid stenosis:
- Data is
still pending from the NASCET study
- VA
Cooperative Study
- Randomized
controlled clinical trial comparing optimal medical therapy vs. CEA in
asymptomatic patients with angiographically documented >50% stenosis
- Ipsilateral
neurologic events over mean follow-up 48 months
- 8% in
CEA group vs. 20.6% in medical group
- However,
study was unable to show a decrease in overall mortality in the CEA group
- ACAS
(Asymptomatic Carotid Artery Stenosis)
- Reduces
stroke risk from 2% to 1% per year
- Benefit
greater in men
- Need
very low surgical complication rate (<2%) to benefit