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 indication shortly.
Medical management include both lifestyle changes and pharmacologic risk reduction.
First antiplatelet therapy, whether that's aspirin or plavix.
Next, statins, as you know cholesterol lowering medications in the statin group have particularly --
are particularly useful for plaque stability.
Remember we use that in some patients with myocardial infarction all the time
and reduce patients high blood pressure, specifically beta blockers.
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.
Unfortunately, these are at best preventative measures.
Here are the indication for surgery.
Our decision tree for offering patient with carotid stenosis surgery
is largely dependent on whether or not the patient has symptoms.
Let's discuss symptomatic patients first.
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.
Of course, patients have to have greater than five years of life expectancy.
This is a particularly important because there are risk associated with this surgery, specifically stroke risk.
As a surgeon before offering the surgery to your patients, you must know your own complication rates.
The benefit have 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, 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.
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.
If your patient is appropriate and meets indication for surgery, we offer carotid endarterectomy.
Here you see surgeon’s busy working at exposure of the neck.
Incisions typically made over the sternocleidomastoid muscle running just along your neck.
After the exposures achieved, this is what we see.
They particularly close the tension 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 expose in 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 bifurcation allowing smoother flow.
Here's the depiction of what actually happens, the yellow plaque is identified, remove from the wall of the vessel.
It remained it at loss bits or tied down so there's no embolic phenomena and subsequently the hole that was made is closed.
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.
Carotid stenting is another available option as well.
While trials have shown that has similar
long term outcomes as an endarterectomy
it does carry a higher periprocedural risk
for the patient.
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.
Thank you very much for joining me on this discussion of carotid stenosis.