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 indications shortly.

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

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

    00:29 Next, statins.

    00:30 As you know, cholesterol-lowering medications in a statin group have particularly – are particularly useful for plaque stability.

    00:39 Remember, we use statins in patients with myocardial infarctions all the time.

    00:44 And reduce patient’s high blood pressure, specifically beta blockers.

    00:50 What about lifestyle changes? Oftentimes much easier recommended than actually achieved by our patients.

    00:57 But if I were you, I would recommend the patient stop smoking, lose weight and decrease their alcohol consumption.

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

    01:10 Here are the indications for surgery.

    01:13 Our decision tree for offering patients with carotid stenosis surgery is largely dependent on whether or not the patient has symptoms.

    01:20 Let's discuss symptomatic patients first.

    01:23 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.

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

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

    01:47 As a surgeon, before offering the surgery to your patients, you must know your own complication rates.

    01:53 The benefit has to outweigh the risks.

    01:57 Next, let’s talk about patients who are asymptomatic at the time.

    02:01 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.

    02:13 Additionally, if a patient has had a previous stroke, myocardial infarction 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.

    02:28 Lastly, remember, annual surveillance for those not undergoing surgery is important.

    02:33 Just because the patient is not a candidate now doesn't mean that their disease may not propagate.

    02:39 If your patient is appropriate and meets indication for surgery, we offer carotid endarterectomies.

    02:45 Here, you see surgeons busy working at exposure of the neck.

    02:50 Incision is typically made over the sternocleidomastoid muscle, running just along on your neck.

    02:56 After the exposure is achieved, this is what we see.

    03:01 Pay particularly close attention to the left side of your screen.

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

    03:12 Shortly, the surgeon will be exposing 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 bifurcations, allowing smoother flow.

    03:26 Here's a depiction of what actually happens.

    03:29 The yellow plaque is identified, removed from the wall of the vessel.

    03:35 The remainder loose bits are tied down, so there's no embolic phenomenon.

    03:40 And subsequently, the hole that was made is closed.

    03:43 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.

    03:56 Now, it's time to visit some important clinical pearls.

    03:59 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.

    04:11 In other words, when most of your patients become symptomatic, surgery is usually required to fix this problem.

    04:18 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. 65% stenosis with symptoms.
    2. 80% stenosis without symptoms.
    3. 5-year life expectancy.
    4. 70% stenosis without symptoms and a risk for MI.
    5. 70% stenosis without symptoms and a risk of stroke.
    1. Angiotensin receptor blockers.
    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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