Carotid artery stenosis - Amboss MBBS students PDF

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4/14/2021

Carotid artery stenosis - AMBOSS

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Carotid artery stenosis

Last updated: February 12, 2021

Summary

Carotid artery stenosis (CAS) is an atherosclerotic, degenerative disease of the common carotid artery and internal carotid artery. Risk factors include advanced age, tobacco use, arterial hypertension, and diabetes mellitus. Depending on the extent of stenosis, ischemia in the carotid perfusion territory can result in amaurosis fugax, TIA, or stroke, and a bruit may be auscultated over the stenosis. Carotid duplex ultrasonography is the initial test of choice for evaluating asymptomatic patients. All symptomatic patients should undergo noncontrast CT or MRI to rule out acute or previous cerebral ischemia. Management depends on symptoms and the degree of stenosis. Lifestyle modications and antiplatelet, antihypertensive, and statin therapy are recommended for all patients. Carotid endarterectomy is recommended for symptomatic patients with a stenosis ≥ 70% and asymptomatic patients with a stenosis ≥ 80%, but may also be considered in highly selected patients with moderate stenosis. Alternatively, if surgery is not feasible, carotid artery stenting may be performed.

Etiology h

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4/14/2021

Carotid artery stenosis - AMBOSS

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Advanced age Tobacco use Arterial hypertension Diabetes mellitus

Clinical features

Many patients are asymptomatic. Carotid bruit (a pathologic sound heard on auscultation over the carotid artery that is caused by turbulent blood ow) Amaurosis fugax Hollenhorst plaque [1] Transient ischemic attack Ischemic stroke

Carotid artery stenosis does not typically cause vertigo, lightheadedness, or syncope.

Diagnostics

First test: carotid duplex ultrasonography (may not detect mild stenosis) Findings: focally increased velocity of blood ow MRA or CTA: indicated for asymptomatic patients with inconclusive ultrasound Noncontrast CT or MRI: indicated for all symptomatic patients (see stroke imaging for details) Digital subtraction angiography (DSA) References:[2][3]

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Carotid artery stenosis - AMBOSS

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Medical management: recommended for all patients Lifestyle modication (see primary and secondary prevention of atherosclerosis) Weight control Smoking cessation DASH diet Regular aerobic physical activity Limited alcohol consumption Pharmacologic therapy as indicated Antiplatelets drugs Statins Antihypertensive drugs Antidiabetic drugs Interventional management: decision to pursue intervention depends on the patient’s symptoms, degree of stenosis, and risk factors Carotid endarterectomy (CEA): a surgical procedure in which the inner lining of a carotid artery is removed, along with any associated atherosclerotic deposits. Indications Symptomatic patients Carotid artery stenosis ≥ 70% Moderate carotid artery stenosis (50%–69%): depends on patient's age, sex, and comorbidities Asymptomatic patients Carotid artery stenosis ≥ 80% Moderate carotid artery stenosis (60%–79%): depends on patient's age, sex, and comorbidities Contraindications Life expectancy of < 5 years Symptomatic carotid artery stenosis < 50% Asymptomatic complete carotid occlusion Prior ipsilateral endarterectomy

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Carotid artery stenosis - AMBOSS

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Carotid artery stenting (CAS): angioplasty and stenting as an alternative to CEA May be considered if surgery is not feasible Increased risk of periprocedural complications compared to CEA References:[3][4][5][6][7]

Complications

Stroke Asymptomatic carotid artery stenosis: annual risk of stroke is 0.5–1% (stenosis > 50%) Carotid artery stenosis is considered an indicator for increased risk of myocardial infarction and cardiovascular death. Complications of CEA (during and after the procedure) Stroke Hypertension and hypotension See “Complications” in endarterectomy. References:[5] We list the most important complications. The selection is not exhaustive.

Prevention

Screening for asymptomatic carotid artery stenosis is only recommended in patients with a high risk of stroke (e.g., age > 65 years, coronary artery disease, dyslipidemia, history of tobacco use) Noninvasive methods (e.g., duplex ultrasonography, MRA) References:[5][8]

References

1. Kaufman EJ, Mahabadi N, Patel BC. Hollenhorst Plaque. StatPearls. 2020 .

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atherosclerosis

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.Last updated: January 31, 2017. Accessed: April 7, 2017.

3. Furie KL. Evaluation of Carotid Artery Stenosis. In: Post TW, ed. UpToDate . Waltham, MA: UpToDate. https://www.uptodate.com/contents/evaluation-of.Last updated: January 30, 2015. Accessed: April 7, 2017.

carotid-artery-stenosis

4. Fairman RM. Management of Symptomatic Carotid Atherosclerotic Disease. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate.

https://www.uptodate.com/contents/management-of-symptomatic-carotidatherosclerotic-disease .Last updated: October 19, 2016. Accessed: December 7, 2016. 5. Fairman RM. Management of Asymptomatic Carotid Atherosclerotic Disease. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate.

https://www.uptodate.com/contents/management-of-asymptomatic-carotidatherosclerotic-disease .Last updated: June 24, 2016. Accessed: December 7, 2016. 6. Carotid Artery Stenosis.

https://www.dynamed.com/topics/dmp~AN~T116329/Carotid-artery-stenosis Updated: June 7, 2017. Accessed: December 21, 2017.

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7. Ricotta JJ, AbuRahma A, Ascher E, Eskandari M, Faries P, Lal BK. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011; 54 (3): p.e1-e31. doi: 10.1016/j.jvs.2011.07.031 . | Open in Read by QxMD 8. Rodriguez AL. Atherosclerotic Disease of the Carotid Artery. In: Lopez Rowe V,

Atherosclerotic Disease of the Carotid Artery . New York, NY: WebMD. http://emedicine.medscape.com/article/463147 . Updated: April 8, 2016. Accessed: April 7, 2017.

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