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Carotid artery stenosis

Last updated: June 18, 2021

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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 modifications 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.

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

  • Approach [2]
    • Symptomatic patients
    • Asymptomatic patients with a bruit : imaging is indicated to identify a hemodynamically significant carotid stenosis
  • Carotid duplex ultrasonography (CDUS)
    • Initial test of choice
    • Direct visualization of the vessel wall and flow measurement
    • Findings
      • Focally increased velocity of blood flow (indicates sites of high-grade stenosis )
      • Increased peak systolic velocity
      • The stenosis is most commonly located within 2 cm of the bifurcation of the common carotid artery.
  • Magnetic resonance angiography (MRA) or CT angiography (CTA)
    • Indications
      • Inconclusive carotid doppler findings
      • Evaluation of stenosis severity and planning for revascularization procedures [2]
    • Findings
      • Reduced residual lumen diameter at the site of the stenosis (compared with the lumen diameter of a normal portion of the carotid artery)
      • Carotid plaques and calcification
  • Digital subtraction angiography (DSA)
    • Gold standard for assessing the carotid arteries (i.e., location of stenosis, number of stenoses, plaque morphology, collateral circulation)
    • Has been replaced by noninvasive procedures due to high costs and increased risk of neurologic complications.
    • Reasonable in patients who cannot undergo CTA/MRA (e.g., renal insufficiency, pacemakers) or in patients with complete carotid artery occlusion to assess whether revascularization is possible
  • 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
    • 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
    • Embolic protection devices

References:[3]

We list the most important complications. The selection is not exhaustive.

  • 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)
  • Pre-operative screening
    • If a CABG is planned, carotid doppler is recommended for asymptomatic patients with or without a bruit
    • If surgery is planned, carotid doppler is recommended in patients with known or suspected CAS (e.g., asymptomatic patient with bruit)
  1. Kaufman EJ, Mahabadi N, Patel BC. Hollenhorst Plaque. StatPearls. 2020 .
  2. Adlova R, Adla T. Multimodality Imaging of Carotid Stenosis. International Journal of Angiology. 2015; 24 (03): p.179-184. doi: 10.1055/s-0035-1556056 . | Open in Read by QxMD
  3. 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