Carotid artery stenosis overview

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Carotid artery stenosis Microchapters

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Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Carotid artery stenosis from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Testing Guidelines

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

CT

MRI

MRA

Echocardiography or Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

ACC/AHA Guideline Recommendations

Diagnostic Testing Guidelines Recommendation

Primary Prevention and Screening Guidelines Recommendations

Secondary Prevention Guidelines Recommendations

Selection of Patients for Carotid Revascularization

Periprocedural Management of Patients Undergoing Carotid Endarterectomy

Management of Patients Undergoing Carotid Artery Stenting

Restenosis After Carotid Endarterectomy or Stenting

Vascular Imaging in Patients With Vertebral Artery Disease

Atherosclerotic Risk Factors in Patients With Vertebral Artery Disease

Occlusive Disease of the Subclavian and Brachiocephalic Arteries

Fibromuscular Dysplasia

Cervical Artery Dissection

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Case #1

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Carotid arterial stenosis is a narrowing of the lumen of the carotid artery, usually by atheroma (a fatty lump or plaque causingatherosclerosis). Atheroma's may cause transient ischemic attacks (TIAs) and cerebrovascular accidents (CVAs) as it obstructs the bloodstream to the brain. It also has the potential to generate emboli (blood clots) that obstruct the cerebral arteries. The narrowing can either be asymptomatic (causing no medical problems) or presents with symptoms such as TIAs and CVAs.

Pathophysiology

Embolism of atherosclerotic lesions in the carotid is the most common mechanism of stroke in patients with carotid artery disease. Thrombosis of the cerebral arteries is also a possible, less common cause of stroke.

Causes

The most common cause of carotid artery stenosis is atherosclerosis. The process of atherosclerotic plaque formation starts in the early adulthood but it takes years for it to cause symptoms. Uncommon causes include Marfan's syndrome and fibromuscular dysplasia.

Risk Factors

Risk factors for carotid artery stenosis are almost similar to those for cerebrovascular accident (CVA), coronary heart disease (ACS) and peripheral vascular disease (PVD). Common risk factors include hypertension, smoking, advanced age and abnormal cholesterol levels including lowered HDL levels in the blood.

Screening

Screening for carotid disease is done before cardiac surgery.

Diagnosis

EKG

The EKG may show evidence of an old infarct or myocardial ischemia. The most common cause of death post-CEA is a myocardial infarction.

CT and MRA

If there is doubt whether the narrowing is still patent (open to blood flow) and the patient is to be assessed for treatment, the next imaging option would either be computed tomography angiogram (CTA) or a magnetic resonance imaging angiogram (MRA). MRA tends to over-estimate the stenosis, but can be used in collaboration with duplex to evaluate the carotid stenosis.

Echocardiography or Ultrasound

Carotid stenosis is usually diagnosed by ultrasound scan of the neck arteries. This is the first imaging option and usually used for follow up and observation as it involves no radiation and no contrast agents that may cause allergic reactions.

Treatment

Medical Therapy

Medical therapy for carotid artery stenosis includes; antihypertensives to control blood pressure, antiplatelet agents, management of lipids, and management of diabetes through tight control of blood glucose levels. Management also includes assessment of the global cardiovascular risk, as well as a yearly surveillance ultrasound, and educating the patient about the symptoms of TIA and stroke.

Surgery

Carotid endarterectomy and stenting are two methods of surgical treatment for carotid artery stenosis.

Secondary Prevention

Secondary prevention for carotid artery stenosis include the cessation of smoking. Other preventative methods which can also be treatment measures are tight control of blood pressure, management of diabetes, and management of lipids.

References

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