Carotid Stenosis: Management

by Kevin Pei, MD

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    00:01 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.

    00:13 We'll go over the surgical indication shortly.

    00:16 Medical management include both lifestyle changes and pharmacologic risk reduction.

    00:22 First antiplatelet therapy, whether that's aspirin or plavix.

    00:28 Next, statins, as you know cholesterol lowering medications in the statin group have particularly -- are particularly useful for plaque stability.

    00:39 Remember we use that in some patients with myocardial infarction all the time and reduce patients high blood pressure, specifically beta blockers.

    00:50 What about lifestyle changes? Often times much easier recommended than actually achieved by our patients but if were you I would recommend the patient stops smoking, lose weight and decrease your alcohol consumption.

    01:05 Unfortunately, these are at best preventative measures.

    01:08 Here are the indication for surgery.

    01:12 Our decision tree for offering patient with carotid stenosis surgery is largely dependent on whether or not the patient has symptoms.

    01:19 Let's discuss symptomatic patients first.

    01:23 In multiple perspective large trials, symptomatic patients with greater than 50% stenosis has diagnosed by imaging modality of choice are usually recommended to have surgery.

    01:34 Of course, patients have to have greater than five years of life expectancy.

    01:39 This is a particularly important because there are risk associated with this surgery, specifically stroke risk.

    01:46 As a surgeon before offering the surgery to your patients, you must know your own complication rates.

    01:53 The benefit have to outweigh the risks.

    01:56 Next, let's talk about patients who are asymptomatic at the time.

    02:00 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.

    02:12 Additionally, if a patient has had a previous stroke, myocardial infraction and you suspect a 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.

    02:28 Lastly remember, annual surveillance from those not undergoing surgery is important just because the patient is not a candidate now doesn’t mean that their disease may not propagate.

    02:38 If your patient is appropriate and meets indication for surgery, we offer carotid endarterectomy.

    02:45 Here you see surgeon’s busy working at exposure of the neck.

    02:50 Incisions typically made over the sternocleidomastoid muscle running just along your neck.

    02:55 After the exposures achieved, this is what we see.

    03:00 They particularly close the tension to the left side of your screen.

    03:04 Blue vessel loops encircle the common carotid, external carotid and internal carotid arteries.

    03:11 Shortly the surgeon will be expose in the carotid arteries, removing the plaque and widening the channel by doing what's called an angioplasty.

    03:20 They'll place a large piece of graft covering all bifurcation allowing smoother flow.

    03:26 Here's the depiction of what actually happens, the yellow plaque is identified, remove from the wall of the vessel.

    03:35 It remained it at loss bits or tied down so there's no embolic phenomena and subsequently the hole that was made is closed.

    03:43 As I previously described the vast majority of surgeons would actually place an angioplasty or a graft in this region so that the repair itself does not become stenotic.

    03:55 Carotid stenting is another available option as well.

    03:58 While trials have shown that has similar long term outcomes as an endarterectomy it does carry a higher periprocedural risk for the patient.

    04:07 For these reasons, it is generally reserved for patients with a very high surgical risk as the shorter procedural time and less invasive nature of stenting may offer a net benefit to the patient.

    04:19 Thank you very much for joining me on this discussion of carotid stenosis.

    About the Lecture

    The lecture Carotid Stenosis: Management by Kevin Pei, MD is from the course Special Surgery.

    Included Quiz Questions

    1. 40% stenosis without symptoms
    2. 80% stenosis without symptoms
    3. 90% stenosis with symptoms
    4. 70% stenosis without symptoms
    5. 50% stenosis with symptoms
    1. Lifestyle changes are not recommended
    2. Antihypertensives
    3. Antiplatelet therapy
    4. Weight loss
    5. Smoking cessation

    Author of lecture Carotid Stenosis: Management

     Kevin Pei, MD

    Kevin Pei, MD

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