Now that you've diagnosed carotid stenosis,
how do we treat these patients?
Remember, most patients with carotid stenosis,
particularly when they’re symptomatic,
will require surgery.
We’ll go over the
surgical indications shortly.
Medical management include
both lifestyle changes
and pharmacologic risk reduction.
First, antiplatelet therapy,
whether that's aspirin or Plavix.
As you know,
cholesterol-lowering medications in
a statin group have particularly –
are particularly useful
for plaque stability.
Remember, we use statins in patients
with myocardial infarctions all the time.
And reduce patient’s high blood
pressure, specifically beta blockers.
What about lifestyle changes?
Oftentimes much easier recommended
than actually achieved by our patients.
But if I were you,
I would recommend the patient stop smoking,
lose weight and decrease
their alcohol consumption.
Unfortunately, these are at best
Here are the indications for surgery.
Our decision tree for offering
patients with carotid stenosis surgery
is largely dependent on whether or
not the patient has symptoms.
Let's discuss symptomatic patients first.
In multiple prospective large trials,
symptomatic patients with
greater than 70% stenosis,
as diagnosed by your imaging modality of choice,
are usually recommended to have surgery.
Of course, patients have to have greater
than five years of life expectancy.
This is particularly important because
there are risks associated with the surgery,
specifically stroke risk.
As a surgeon,
before offering the surgery to your patients,
you must know your own complication rates.
The benefit has to outweigh the risks.
Next, let’s talk about patients who
are asymptomatic at the time.
Patients who have asymptomatic,
meaning no TIAs,
no amaurosis fugax,
who have high grade stenosis
as defined by greater than 80%,
are usually offered surgery.
Additionally, if a patient has had a previous stroke,
and you suspect the chance of death
for the surgery is less than 3%,
then if their carotid stenosis
is greater than 70%,
they should also be offered surgery.
annual surveillance for those not
undergoing surgery is important.
Just because the patient
is not a candidate now
doesn't mean that their
disease may not propagate.
If your patient is appropriate
and meets indication for surgery,
we offer carotid endarterectomies.
Here, you see surgeons busy
working at exposure of the neck.
Incision is typically made over
the sternocleidomastoid muscle,
running just along on your neck.
After the exposure is achieved,
this is what we see.
Pay particularly close attention
to the left side of your screen.
Blue vessel loops encircle
the common carotid,
external carotid and internal carotid arteries.
Shortly, the surgeon will be
exposing the carotid arteries,
removing the plaque and widening the
channel by doing what's called an angioplasty.
They’ll place a large piece of
graft covering all bifurcations,
allowing smoother flow.
Here's a depiction of what actually happens.
The yellow plaque is identified,
removed from the wall of the vessel.
The remainder loose bits are tied down,
so there's no embolic phenomenon.
And subsequently, the hole
that was made is closed.
As I previously described,
the vast majority of patient –
surgeons would actually place
an angioplasty or a graft in this region,
so that the repair itself
does not become stenotic.
Now, it's time to visit
some important clinical pearls.
Remember, for carotid stenotic patients,
aggressive medical management for
preventative measures is very important,
although current evidence suggests
that it s not sufficient as monotherapy.
In other words,
when most of your patients become symptomatic,
surgery is usually required to fix this problem.
Thank you very much for joining me
on this discussion of carotid stenosis.