Carotid stenosis, stroke, and carotid artery revascularization
Introduction
Atherosclerotic carotid artery stenosis is an important cause of stroke. Plaque can and does occur anywhere along the carotid artery axis from its origin from the aorta arch to its terminus intra-cranially. However, the term “carotid artery stenosis” usually refers to plaque at the common carotid artery bifurcation involving the origin of the internal carotid artery and carotid bulb, which accounts for the majority of clinical stroke events. Carotid artery stenosis is more common in patients with risk factors for atherosclerotic vascular disease, such as hypertension, dyslipidemia, diabetes, smoking and family history of vascular disease. However, perhaps due to the unique configuration of the carotid bulb, severe atherosclerotic carotid stenosis can occur in patients with minimal or seemingly no risk factors for vascular disease. Intensive medical treatment of comorbid vascular risk factors is always necessary for patients with carotid atherosclerosis. Open or endovascular surgeries, such as carotid endarterectomy (CEA), carotid stenting (CAS) and transcarotid artery revascularization (TCAR) are sometimes indicated for the primary or secondary prevention of stroke.
Section snippets
Pathophysiology and common symptoms
Carotid artery stenosis, even when severe, is frequently asymptomatic. This is because most patients have Circle of Willis (COW) collaterals which compensate well for any reduction in blood flow caused by a cervical carotid stenosis. While COW anatomy is highly variable, most patients have an anterior communicating artery, posterior communicating artery, or both which may preserve normal blood flow to the brain in the event of cervical carotid artery stenosis or occlusion. Failing that, the
Imaging diagnosis
Carotid stenosis can be diagnosed non-invasively by carotid ultrasound (CUS), CTA or MRA. All three have advantages and disadvantages.
Carotid ultrasound evaluates carotid stenosis by peak systolic velocity (PSV) and end diastolic velocity (EDV) of blood flow, combined with grey scale image findings and spectral waveform analysis. CUS is unique in providing physiologic information about carotid stenosis, whereas the other techniques are essentially anatomic. The test is very much operator
Treatment and outcomes
Surgical treatment of severe (>70%), symptomatic carotid artery stenosis with carotid endarterectomy (CEA) became standard of care after the publication of the North American Symptomatic Carotid Endarterectomy Trial (NASCET) in 1991.4 CEA for asymptomatic carotid stenosis also was widely accepted following the publication of two randomized trials indicating an approximately 5–6% absolute risk reduction over a 5 year period compared with non-surgical management.10,11 As medical treatments for
Summary
Carotid artery stenosis is an important cause of ischemic stroke. All patients who have carotid stenosis benefit from attentive medical treatment of vascular risk factors. Some patients benefit from carotid revascularization procedures, such as CEA, CAS and TCAR. The most powerful tool for the treatment of carotid disease is not, however, any specific medication, nor is it carotid endarterectomy, nor is it a carotid stent, no matter what method is used to deploy it. And while randomized data
COI/Disclosures
Don Heck, MD: consultant for Stryker.
Alec Jost: None to disclose.
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