Carotid artery stenosis
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This document summarizes the treatment options for carotid artery stenosis, specifically carotid endarterectomy (CEA) versus carotid artery stenting (CAS). CEA has been shown to be superior to medical management alone in reducing stroke risk and is the gold standard treatment. CAS may be preferable for high-risk patients with conditions making CEA difficult, but is associated with a higher risk of perioperative stroke. The choice between CEA and CAS depends on patient characteristics, disease factors, and operator experience. While CAS can be performed less invasively, current evidence shows CEA remains the standard treatment for standard-risk patients.
Carotid artery stenosis
- 1. Carotid Artery Stenosis ENDARTERECTOMY vs STENTING
- 2. Keywords 1. CAS 2. CEA 3. BMT
- 3. Prevalence ICA stenosis is estimated to be 2% to 3% in the general population, with increased prevalence noted in men and the elderly
- 4. Carotid atheroma The bifurcation point of the common carotid artery, or carotid bulb,is predisposed to the development of atherosclerosis owing to low wall shear stress and resulting flow stagnation. Narrowing or stenosis of the carotid bulb and ICA because of atherosclerosis can lead to ischemic stroke secondary to plaque embolization or hypo-perfusion
- 5. Risk factors • Smoking • Hypertension • Hyperlipidemia • coronary artery disease (CAD) • diabetes mellitus • peripheral arterial disease • abdominal aortic aneurysm • Racial predilection
- 6. Transient ischemic attacks Stroke like symptoms that last <24 hours, are also associated with an increased risk of early recurrent stroke, particularly in patients with carotid artery atherosclerosis.
- 7. STROKE Acute development of a focal neurological deficit attributable to the disruption of blood flow to the brain, is caused by ischemia or haemorrhage. The majority (>80%) of strokes are of ischemic aetiology, of which ≈15% to 20% are attributable to atherosclerosis of the extra cranial carotid arteries. The risk of death and recurrent stroke increases following an ischemic stroke.
- 8. ENDARTERECTOMY surgical removal of part of the inner lining of an artery, together with any obstructive deposits, most often carried out on the carotid artery or on vessels supplying the legs.
- 9. STENTING In medicine, a splint placed temporarily inside a duct, canal, or blood vessel to relieve an obstruction
- 10. Diagnosis 1. Non-invasive :Duplex ultrasound, computed tomographic angiography, and magnetic resonance angiography have essentially replaced cerebral angiography, given their high sensitivity and specificity for identifying high grade carotid stenosis. 2. Invasive : Conventional cerebral angiography is considered the gold standard test for the diagnosis of carotid artery stenosis
- 11. Prevent stroke 1. Best medical therapy (BMT) 2. Carotid endarterectomy (CEA) 3. Carotid artery stenting (CAS)
- 12. Decision is affected by 1. Patient factors:Age,sex,life expectancy ,comorbidity, operative risk ,preference 2. Disease factors: Risk of stroke and anatomical consideration 3. Skill of the operator 1. a minimum of 30 to 150 diagnostic cervicocerebral angiograms, and 25 to 75 CAS procedures 2. operator volume of ≥6 cases per year and center experience of >150 CAS procedures associated with the best outcomes
- 13. CREST and metanalysis Age ≥70 years has been associated with increased periprocedural risk with CAS in comparison with CEA
- 14. Unstable plaques 1. Ulceration 2. intraplaque haemorrhage on MRI 3. rapid progression 4. increased plaque area 5. plaque heterogeneity with increased echolucency 6. low grey-scale 7. Presence of discrete white areas within the plaque.
- 15. Hostile neck 1. Previous radical neck surgery 2. External beam radiotherapy 3. Contralateral laryngeal nerve palsy 4. Tracheostomy
- 16. Hostile carotid Plaque distal to the C2 vertebral body or proximal to the clavicle because they are difficult to tackle surgically ICA-common carotid artery angulation >60 degrees, target ICA lesion >10 to 15 mm in length, ostial involvement of the lesion, and excessive calcification have been associated with worse outcomes in CAS-treated patients in comparison with CEA-treated patients
- 17. CEA is gold standard 1. 2 large RCTs in the 1990s (NASCET, ECST) demonstrated the superiority of CEA over medical management for stroke prevention. 2. 2 large asymptomatic trials (ACAS, ACST) also showed a small (6%) reduction in stroke rate with CEA at 5 years in comparison with medical therapy. 3. Asymptomatic patients for CEA is guided by a detailed assessment of patient life expectancy, comorbid conditions, surgeon/institution stroke rate, and patient preference.
- 18. CAS 1. introduction in 1980 2. Use of stent and embolic protection devices 3. Endovascular tools and equipment 4. New antiplatelet drugs 5. Not superior to CAE
- 19. CEA vs CAS
- 20. Advantages of CAS 1. Lower risk of perioperative MI 2. Suitable option for high-risk patients 3. Suitable option for patients with hostile neck or hostile carotid 4. Can be performed under local/regional anaesthesia
- 21. Disadvantages of CAS 1. Higher risk of perioperative stroke 2. Associated with worse outcomes in symptomatic patients and the elderly 3. Not a suitable option for patients with lesions at high risk of periprocedural embolization 4. Evidence for noninferiority in standard-risk and asymptomatic patients is limited
- 23. Current evidence CEA is the gold standard Rx when the patient is not at high operative risk attributable to a hostile neck or significant comorbidities