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.