Carotid Artery Disease and management

Naylor R et al., European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic
Carotid and Vertebral Artery Disease, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2022.04.011

Definitions

TIA – REVERSIBLE NEUROLOGICAL DEFICIT <24hrs

Stroke in evolution refers to a fluctuating neurological deficit (without full recovery), or a
progressively worsening neurological deficit over 24 hours
Crescendo TIAs refer to multiple TIAs in a short time period, defined by some as more than
two TIAs in 24 hours.
Stroke is a sudden onset focal (rather than global) neurological dysfunction, with symptoms
lasting > 24 hours

Causes

1. Large vessel atherosclerosis defined as >50% stenosis of an extracranial vessel = 16%

of trokes
2. Cardioembolic
3. Small vessel occlusion
4. Other aetiologies like arteritis, dissection

Asymptomatic CEA
>50% Stenosis
For these patient councelling is recommended to improve diet, stop smoking best DM
control, BP, DM
Also Low dose aspirin 75mg= prevents death from Mis as most have underlying CAD
If intolerant to aspirin then low dose CLOPIDOGREL, If intolerant then dipyridamole 200mg

If are due to have CAS (Carotid artery stenting) then Dual AP is needed before surgery –
Aspirin + Clopidogrel

In symptomatic pt If CEA is considered then dual AP should be started once bleeding is

excluded
If monotherapy is chosen instead then aspirin 300-325 mg daily for 14 days, followed by
clopidogrel 75-162 mg daily should be considered

Treatment

Symptomatic group
>=70% Stenosis = CEA +BMT (Level1 evidence)
>60-69% Stenosis = again CEA +BMT (But level 2 evidence)
>50% + those with near occlusion need BMT first and if recurrence stroke then they can be
considered for CEA+BMT OR CAS+BMT

Asymptomatic
>60% If high risk findings . >5 year prognosis then CEA +BMT If not BMT
Oclussion or near occlusion or <60% stenosis = BMT Level 1
Procedure related complications and Mx

For patients who develop an ipsilateral neurological deficit after flow is restored following
carotid clamp release when carotid endarterectomy is performed under locoregional
anaesthesia, immediate re-exploration of the carotid artery is recommended.

Following CEA Pt can develop a haemaotoma which can compromise the airway and a
prophylactic wound dressing is recommended

For patients undergoing carotid artery stenting, intravenous atropine or glycopyrrolate is

recommended prior to balloon inflation to prevent hypotension, bradycardia or asystole.

Hyperperfusion Syndrome may be characterised by headache, confusion, atypical

migraineous phenomena, seizures, hypertension, decreased consciousness, nausea and
vomiting, and (ultimately) a neurological deficit, which can be due to vasogenic oedema,
ischaemia, or haemorrhage. The average time of symptom onset is 12 hours post-operatively,
although it can occur up to four weeks later.

Prosthetic patch and stent infection

1% of pt , organisms Staph , stept
Treatment is removal and repair with autologous venous patch is recommended

Symptomatic Re-stenosis
>50%= re-do CEA
<50% = BMT