Carotid atherosclerosis

Surgical treatment of carotid atherosclerosis

Experience of ONMedU University Clinic
PATHOGENESIS
• Pre-atherosclerosis: Hemodynamic endothelial trauma + HYPER LDL

• Atherosclerosis: Lipid deposition + immune aggression

• Atherothrombosis: stenosis + occlusion

RISK FACTORS
MODIFIED UNMODIFIED
Tobacco smoking Genetic position
Dyslipidemia Family anamnesis
Arterial hypertension Age [> 50]
Diabetes Sex [♂]
Insulin resistance
Alimentary Obesity
Stroke statistics
• Stroke is the second most frequent cause (11% of the total)of
death after coronary artery disease.
• The incidence in the world of 15 million people per year.
• It accounts for 6.3 million deaths and for the same work inability.
• About 3.0 million deaths resulted from ischemic stroke and
3.3 million deaths resulted from hemorrhagic stroke.
• About half of people who have had a stroke live less than one year.
• Two thirds of strokes occurred in those over 65 years old.
Protocol
Self-estimating
Pre-hospital estimating
Pre-hospital estimating
Hospital estimating
Diagnosis
For diagnosing ischemic (blockage) stroke in the emergency setting
CT scans (without contrast enhancements)
sensitivity= 16% (less than 10% within first 3 hours of symptom onset)
specificity= 96%
•MRI scan
sensitivity= 83%
specificity= 98%
For diagnosing hemorrhagic stroke in the emergency setting:
•CT scans (without contrast enhancements)
sensitivity= 89%
specificity= 100%
•MRI scan
sensitivity= 81%
specificity= 100%
For detecting chronic hemorrhages, MRI scan is more sensitive.
• The National Institute for Health and Care Excellence (NICE)
recommends that people who have had a stroke or TIA and have a
moderate or severe stenosis should have a carotid endarterectomy.
• The operation will ideally be carried out within 2 weeks of when your
symptoms started.
• Having surgery gives the best chance of preventing a further stroke if
it's performed as soon as possible.
 Asymptomatic
• Carotid endarterectomy is considered in patients with an “average surgical risk” without
symptoms with carotid artery stenosis of 60-99%, provided there are clinical signs of an increased
risk of stroke if the perioperative stroke / mortality rate is <3% and the patient has a life
expectancy> 5 years
• IIa B
• Carotid endarterectomy is considered in patients with an “average surgical risk” without
symptoms with carotid artery stenosis of 60-99%, provided there are visual signs of an increased
risk of stroke, if perioperative stroke / mortality rate <3% and patient life> 5 years
• IIa B
• Stenting is considered an alternative with an “average surgical risk” without symptoms with
carotid artery stenosis of 60-99%, provided that there are visual signs of an increased risk of stroke
if the perioperative stroke / mortality rate is <3% and the patient's life expectancy is> 5 years
• IIb B

Management of Atherosclerotic Carotid and Vertebral Artery Disease (January 2018)

 Symptomatic
• Carotid endarterectomy is recommended in patients with symptoms / with stenosis of
the carotid arteries of 70-99%, provided that the recorded frequency of perioperative
stroke and death is <6%.
• IA
• Carotid endarterectomy is considered in patients with symptoms / with stenosis of the
carotid arteries of 50-69%, provided that the recorded frequency of perioperative
stroke and death is <6%.
• Iia a
• Carotid stenting is considered in patients with "high surgical risk" / with stenosis of the
carotid arteries of 50-99%, provided that the recorded frequency of perioperative
stroke and death is <6%.
• IIa B
Management of Atherosclerotic Carotid and Vertebral Artery Disease (January 2018)
Journal of Vascular Surgery, 66(2), 607–617. doi:10.1016/j.jvs.2017.04.053
X-ray

Resonant
X-ray

Resonant
X-ray

Resonant
 • Duplex Scanning (DS) CT angiography (CTA) MR angiography (MRA) is
recommended for assessing the extent and severity of extracranial
stenosis of the carotid arteries.
•IB
• When planning a carotid endarterectomy, it is recommended to
control the DS of stenosis assessment using CTA or MRA.
•IB

Management of Atherosclerotic Carotid and Vertebral Artery Disease (January 2018)

ANDROID SUPPLY
 Carotid Endarterectomy
Removal of plaque and intima from bifurcation of the carotid arteries.

First performed by Michael Debacke in 1953, a man aged 53 years with

a TIA.

Today, it is firmly entrenched in the practice of carotid surgery as the

gold standard for stroke prevention.
 Classic technique

Arterial skeletonization
Holders and Clips application
Systemic heparinization
Arteriotomy of the ICA and
CCA
Plaque dissection
Adapting and fixing the patch
Eversion technique

Arterial skeletonization
Holders and Clips application
Systemic heparinization
ICA resection
ICA Eversion
Plaque dissection
ICA reimplantation
Palliative
Prophylactic
2013 2014 2015 2016 2017 2018 2019 ВСЕГО
15 26 37 32 57 63 64 294
 
Planned 276 Urgent
 

/11
  /0
 
 P ostoperative death 0  P ostoperative death 1

 
RATE
STROKE UNIT𝟒 / 𝟒 / 𝟏𝟔
 

Prenotification phone
Red channel
Emergency CT GM
4.5 hour window
ACUTE stage ONMK
Intensive care unit
MULTIDISCIPLINARY
 SYMPTOMATIC PATIENTS
TRANSITOR ISCHEMIC ATTACK
“MINOR” DISORDERS OF BRAIN
BLOOD CIRCULATION
NEUROLOGICAL DEFICIENCY (motor,
vision, articulation)

х  100%

European Carotid Surgery Trial (ECST) 50%

North American Symptomatic

Carotid Endarterectomy Trial (NASCET)  70%
 Contraindications
POSTINSULTAL NEUROLOGICAL DEFICIENCY NIHSS> 15)
TOTAL OCCASION OF THE CAROTID ARTERY (conta / homo)
Patient age ≥80 years
Angina pectoris III / IV
Heart Failure III / IV
KIDNEY FAILURE
RESPIRATORY FAILURE
Cachexia
LVEF (by SIMPSON) ≤ 30%
Acute myocardial infarction (30 days)
Anesthesia

90%
Plexus cervicalis
superficalis
Heparine OBLIGATE
Independent on coagulation
Intraoperative

INJECTION
Protamine OBLIGATE
Independent on coagulation
Intraoperative

INJECTION
Heparine OPTIONAL
Dependent on coagulation
Postoperative

INFUSION
Statins are recommended for all patients with peripheral artery disease
IA
Physical activity is recommended for all patients with peripheral arterial disease.
IA
Smoking cessation is recommended for all patients with peripheral arterial disease.
IB
A healthy diet is recommended for all patients with peripheral arterial disease.
IC
Antiplatelet therapy is recommended for all patients with peripheral arterial disease.
IC
Arterial pressure control is recommended for all patients with peripheral arterial disease.
IA
Glucose Level control is recommended for all patients with peripheral artery disease
IC
Lipid control is recommended for all patients with peripheral artery disease.
IC
INDICATIONS
Symptomic patients > 50%
Asymptomatic patients > 60%

ANESTHESIA
Regional plexus block 90%
TOTAL intravenous anesthesia 10%

HEMOSTASIS
PROTAMINE 100% at the end of the vascular stage

CONTROL
Antiplatelet and Anticoagulation according to hemovisimetry

PREVENTION
Aspirin, clopidogrel, atorvastatin for long-term use