CAROTID

ARTERY
DISEASE
By Laetitia Layoun
September 2019
Definition
Carotid Artery Disease OR Carotid Stenosis:
- Narrowing of the carotid arteries, the two major arteries that carry oxygen-rich
blood from the heart to the brain  due to build up of plaque (atherosclerosis)
- Reduced blood flow to the brain  risk of Stroke
- Carotid stenosis is estimated to cause 20 to 30% of all strokes
Blood Supply from the Carotids
EXTERNAL CAROTID ARTERY BRANCHES: INTERNAL CAROTID ARTERY BRANCHES:

!! Most common site of plaque buildup is at the bifurcation of the common carotid artery (close to larynx)
Plaque Formation
• As we age, hypertension and small injuries to the blood vessel wall can allow
plaque to build up
• Plaque = fat, cholesterol, calcium, and other fibrous material
• Atherosclerosis also causes arteries to become rigid, a process often referred to
as “hardening of the arteries”
Risk Of Stroke
• 3 ways in which carotid plaque increases risk of stroke:
1) Plaque deposits can grow larger and larger, severely narrowing the artery and
reducing blood flow to the brain. Plaque can eventually completely block
(occlude) the artery
2) Plaque deposits can roughen and deform the artery wall, causing blood clots
to form and blocking blood flow to the brain
3) Embolization  Plaque deposits can rupture and break away, traveling
downstream to lodge in a smaller artery and block blood flow to the brain
Risk Of Stroke (2)
Risk Factors
• Risk Factors = Age, Smoking, Diabetes, Hypertension, Dyslipidemia, Obesity,
CAD, family history
• Less commonly, carotid aneurysm and fibromuscular dysplasia can cause
carotid stenosis
• People with CV disease are at increased risk  typically, carotids become
diseased few years later than the coronary arteries
• Before age 75, men are more at risk than women
 Screening

Screening depends on the presence of symptoms or other risk factors :

The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening in asymptomatic
American Heart Association recommends screening for people who don’t have symptoms of carotid stenosis but
have been diagnosed with related medical conditions or have risk factors for carotid artery disease
Vascular disease elsewhere in the body, including: (PAD) (CAD) (AAA)
Two or more of the following risk factors: hypertension, hyperlipidemia, smoking, Family history
Physician detects: a carotid bruit, or murmur.
Signs & Symptoms
• Most people are asymptomatic until the artery is severely narrowed or a clot forms
• Symptoms:
- TIA (weakness or numbness in an arm or leg, difficulty speaking, a drooping face, vision
problems, or paralysis affecting one side of the body)
- Amaurosis fugax
- Stroke-in-evolution
- Cerebral infarction
• Signs:
- Carotid bruit on auscultation
 Diagnosis
• Lab workup:
- CBC
- Electrolytes, blood urea nitrogen (BUN), and creatinine
- Lipid profile
- PT, PTT (pre-op)
• Imaging:
-Carotid duplex ultrasonography (US) (used to determine % of vessel narrowing)
-CT angiogram of the neck
-MRA
-Cerebral Angiogramy (insertion of catheter from the groin to visualize the vessels in the neck & brain)
Carotid Duplex Ultrasonography
Angiogram

Angiogram of the carotid artery showing a narrowing of the vessel caused by

atherosclerotic plaque (red arrow)
Medical Treatment
Given to patients who are asymptomatic with low-grade carotid stenosis (<50%) & to
patients who have a medical condition that would increase the risk of surgery
• Aspirin (30-1350 mg/day)  significant reduction in stroke risk & TIA
• Statins; Atorvastatin, Rosuvastatin, Simvastatin, Pravastatin (recommended for all
patients with extracranial carotid atherosclerotic disease); target LDL<100; target of
LDL<70 in high-risk patients
• Clopidogrel (75 mg/day)/Ticlopidine (250 mg q12hr)  inhibit platelet aggregation;
10% more effective than Aspirin; toxicity may induce neutropenia & diarrhea (less in
Clopidogrel)
• Warfarin (controversial for use in pts with noncardiac emboli)  titrated INR of 2-3
 Asymptomatic

Intensive medical therapy using all available risk reduction strategies including:

statin therapy, antiplatelet therapy, blood pressure control, and lifestyle modification consisting
of smoking cessation, limited alcohol consumption, weight control, physical activity, diet

For medically stable patients who have a life expectancy of at least five years and a high grade (≥80
percent) asymptomatic carotid stenosis at baseline or have progression to ≥80 percent stenosis despite
intensive medical therapy while under observation, we suggest carotid endarterectomy (CEA), provided
the combined perioperative risk of stroke and death is less than 3 percent for the surgeon and center
 Carotid Endarterectomy (CEA)

Indications:
• Symptomatic patient with 70-99% stenosis  Clear benefit (incidence of ipsilateral stroke in 2 years 9% with
surgery compared to 26% with medical management)
• Symptomatic patients with 50-69% stenosis  Modest benefit (greater benefit in males)
•Asymptomatic patients with greater than 60% stenosis  Benefit is significantly less than for symptomatic
patients with 70-99% stenosis
Contraindications:
• Patients with a severe neurologic deficit after a cerebral infarction
• Patients with an occluded carotid artery
•Stenosis due to radiation
•lesion that is not suitable for surgical access.
• Concurrent medical illness that would significantly limit the patient’s life expectancy
Carotid Endarterectomy (2)
• Definition:
- Open surgery to remove the plaque in the carotid arteries in the neck & prevent stroke
• Procedure:
1) A skin incision is made along the anterior border of the SCM & curves posteriorly 1 cm
below the angle of the mandible to avoid injury to the facial nerve
2) The dissection is carried down to the carotid sheath to expose the carotid arteries
Carotid Endarterectomy (3)
• Procedure (Cont’d):
3) The endarterectomy is carried out in a smooth plane in the media of the artery
4) The plaque buildup is peeled out and removed
Carotid Endarterectomy (4)
• Procedure (cont’d):
5) The endarterectomy is closed either primarily or with a patch, allowing blood to
flow to the brain
Post-op Care
• Hemodynamic monitoring is important, with a focus on maintaining the patient’s
blood pressure at its preoperative range
• The patient is observed for the formation of a hematoma that may compromise the
airway
• Antiplatelet therapy is necessary
• Patients are evaluated 2 weeks postoperatively for wound or neurologic complications
• Carotid duplex US is performed after 6 months and annually thereafter
Carotid Angioplasty & Stenting (CAS)
CEA remains standard of care; most of the trials published to date have shown varying
results with CAS
Indications:
• Symptomatic patients with high-grade stenosis (≥70%) who are considered to be at high
risk for CEA
• Symptomatic patients with 50-70% stenosis who are considered to be at high risk for CEA
• Patients who are at high risk for CEA and have asymptomatic carotid stenosis of 80% or
higher
• Patients who have stenosis that was caused by prior radiation therapy
Challenge  patients with a high risk of poor outcome after CEA can not be reliably
identified, and the existence of such a group of high-risk patients has been challenged
Carotid Angioplasty & Stenting (2)
• Periprocedural (30-day) risk of stroke and death may be higher with CAS than in CEA
but the risk of stroke or death beyond 30 days is similar for both techniques
• Definition:
-Minimally invasive endovascular procedure that compresses the plaque and widens the
lumen of the artery
- Performed during an angiogram in a radiology suite
• Procedure:
1) A flexible catheter is inserted in the femoral artery in the groin
2) It is guided through the blood stream past the heart, and into the carotid artery
Carotid Angioplasty & Stenting (3)
• Procedure (cont’d):
3) A small catheter with an inflatable balloon at the tip is positioned across the plaque
4) The balloon is opened to dilate the artery and compress the plaque against the artery
wall
Carotid Angioplasty & Stenting (4)
• Procedure (cont’d):
5) The balloon is then deflated and removed
6) A stent is placed over the plaque, holding open the artery
Carotid Artery Bypass
• Reroutes the blood supply around the plaque-blocked area
• A length of artery or vein is harvested from somewhere else in the body, usually the
saphenous vein in the leg or the ulnar or radial arteries in the arm
• The vessel graft is connected above and below the blockage so that blood flow is
rerouted (bypassed) through the graft
• Bypass is typically only used when the carotid is 100% blocked (carotid occlusion)
Complications
• Cranial nerve injuries (in 2-7% of patients)
• Recurrent laryngeal and hypoglossal nerve dysfunctions (most common)
• Postoperative stroke (1-5% of patients)
• Recurrent stenosis (1-20% of cases) – reoperation is necessary in only 1-3% of cases
• Female sex, diabetes, and dyslipidemia are independent predictors of restenosis or
occlusion at 2 years after either CEA or CAS
• Smoking is also an independent predictor of restenosis in patients who underwent CEA
only
Recovery & Prevention
• After carotid endarterectomy, restenosis can occur in less than two years and is usually
not symptomatic. These regrown plaques can be treated with angioplasty and stenting
or repeat surgery (ONLY if stenosis is >80% or symptomatic)
References
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for
Asymptomatic Carotid Artery Stenosis. JAMA 273:1421-28, 1995
Barnett HJ, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe
stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med
339(20):1415-25, 1998
Hobson RW 2nd, et al.; Society for Vascular Surgery. Management of atherosclerotic carotid artery disease:
clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg 48(2):480-6, 2008
https://www.uptodate.com/contents/management-of-symptomatic-carotid-atherosclerotic-
disease?search=carotid%20endarterectomy&source=search_result&selectedTitle=4~65&usage_type=defa
ult&display_rank=4#references
THANK YOU