Atherosclerotic Disease of the Carotid Artery

No Results

No Results

processing….

Atherosclerosis is a diffuse, degenerative disease of the arteries that results in the formation of plaques composed of necrotic cells, lipids, and cholesterol crystals. These plaques can cause stenosis (see the image below), embolization, and thrombosis. Atherosclerosis has a predilection for certain arteries, including the extracranial carotid artery.

Atherosclerotic disease of the carotid artery may be associated with the following:

See Overview for more detail.

Indications

Indications for carotid endarterectomy (CEA), based on prospective randomized trials, include the following:

Note: The percentage of stenosis used as the threshold for CEA varies among available literature. Generally, symptomatic patients with greater than 50% stenosis and healthy, asymptomatic patients with greater than 60% stenosis warrant consideration for CEA.

Contraindications

Contraindications for CEA include the following:

Studies to be considered include the following:

See Workup for more detail.

Treatment of atherosclerosis of the carotid artery is dependent on the severity and degree of the disease.

Pharmacotherapy

Medications used to manage atherosclerotic disease of the carotid artery include the following:

Surgery

Endovascular management of atherosclerotic disease of the carotid artery includes the following procedures:

See Treatment for more detail.

Atherosclerosis is a degenerative disease of the arteries that results in the formation of plaques composed of necrotic cells, lipids, and cholesterol crystals (see the images below). These plaques can result in symptoms by causing stenosis, by embolizing, or by thrombosing. Atherosclerosis is a diffuse process with a predilection for certain arteries. This article describes the history and impact of this process as it occurs in the extracranial carotid artery.

For patient education resources, see the Brain and Nervous System Center and the Cholesterol Center, as well as Stroke, High Cholesterol, Understanding Your Cholesterol level, and Lifestyle Cholesterol Management.

The carotid artery originates from the innominate artery on the right and directly from the aortic arch on the left. The carotid artery enlarges in the midneck, forming the carotid bulb, before bifurcating into the external and internal carotid arteries. The carotid sinus and carotid body are located at the bifurcation (see the image below).

Currently, embolization is considered the most common mechanism causing ischemic strokes from atherosclerotic lesions in the carotid bulb. Thrombosis and low flow are other possible mechanisms.

Stroke is one of the most devastating complications of carotid stenosis. However, carotid stenosis is not the only cause of stroke. In fact, among patients with asymptomatic stenosis of 60-99%, as many as 45% of strokes may be caused by lacunar infarcts or cardiac emboli.

Stroke from any cause represents the third leading cause of death in the United States. Half a million new strokes occur each year in the United States, resulting in approximately 140,000 deaths. Stroke is the leading cause of serious long-term disability in the United States. In 2017, the direct and indirect cost of stroke in the United States was estimated at $34 billion. [2]

Cranial nerve injuries occur in 2-7% of patients. Recurrent laryngeal and hypoglossal nerve dysfunctions are the most common. Postoperative stroke occurs in 1-5% of patients. [1] The perioperative mortality is 0.5-1.8%. Recurrent stenosis develops in 1-20% of cases, and reoperation is necessary in 1-3% of cases.

In the North American Symptomatic Carotid Endarterectomy Trial (NASCET), the 2-year stroke risk after a successful carotid endarterectomy (CEA) was 1.6%, compared with 12.2% for the medically managed patients. [1] The cumulative risk of an ipsilateral stroke was 9% for the surgical patients and 26% for the medically managed patients.

In the Asymptomatic Carotid Atherosclerosis Study (ACAS), the 5-year risk for ipsilateral stroke was 5.1% for the surgical group and 11% for the medical group. [3] The stroke risk of arteriography was attributed to the surgical group and was 1.2%.

The Endarterectomy Versus Stenting in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S) trial revealed a higher stroke and death rate with carotid artery stenting (CAS); however, cerebral protection was not uniformly used, and dual antiplatelet therapy was not initiated on all patients. [4]

A meta-analysis revealed that protected (use of an embolic protection wire) CAS was associated with an 8.2% rate of stroke or death at 30 days, compared with 6.2% for surgery [5] ; however, the rates of disabling stroke or death within this period were not significantly different between the two groups.

Meier et al conducted a systematic review and meta-analysis of 11 randomized controlled clinical trials to evaluate the relative short-term safety and intermediate-term efficacy of CEA versus CAS. [6] CEA carried a lower risk of periprocedural mortality or stroke than CAS did, mainly because of a decreased risk of stroke. However, the risk of death and the composite endpoint of mortality or disabling stroke did not differ significantly between the two procedures. In addition, the odds of periprocedural myocardial infarction (MI) or cranial nerve injury (CNI) were higher among the CEA group as compared with the CAS group. In the intermediate term, the risk of stroke or death did not differ significantly between the two.

Numerous studies, including the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial, have found that CAS is not inferior to CEA at 1 year. Published long-term results show no significant difference between groups in the prespecified secondary endpoint trial, a composite at 3 years of death, stroke, or MI within 30 days of the procedure (or death or ipsilateral stroke between 31 and 1080 days). [7]

A study by Illuminati et al suggested that with regard to the timing of CEA, previous or simultaneous CEA in patients with unilateral severe asymptomatic carotid stenosis (>70%) undergoing coronary artery bypass grafting (CABG) was better able to prevent stroke than delayed CEA was. [8] The overall surgical risk was not increased.

A study by Brown et al suggested that the risk of external carotid artery occlusion may be lower with CEA than it would be with CAS, though such occlusion after CAS was still uncommon overall (~4%) and was not associated with in-stent restenosis. [9]

The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) evaluated the outcomes of 2502 patients with symptomatic or asymptomatic carotid stenosis after undergoing CAS or CEA, and found that the risk of stroke, MI, or death was similar between the two procedures. [10]

Although there was no difference in the primary outcome of CREST, there was a higher risk of periprocedural stroke in the group who underwent CAS, whereas there was a higher risk of MI in the group undergoing CEA. [10]  Additional analysis, however, indicated that stroke had an adverse long-term effect on quality-of-life measures, whereas MI did not. Further study of the CREST data showed that 4-year mortality was significantly higher in patients who had a stroke after intervention (21.1% vs 11.6%). [11]

Whereas CNI occurred in 4.6% of the CREST patients who underwent CEA, there was a 80% rate of resolution at 1 year, and there was no statistical difference in health-related quality-of-life outcomes between patients who had CNI and those who did not. [12]

Brott et al carried out a pooled analysis of individual patient data (N = 4754) from the EVA-3S, SPACE (Stent-Protected Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy), ICSS (International Carotid Stenting Study), and CREST trials to compare long-term outcomes of CEA and CAS for treatment of symptomatic carotid stenosis. [13]  Patients were followed for a maximum of 12.4 years (median follow-up, 2.0-6.9 years). The primary outcome was the composite risk of stroke or death within 120 days after randomization (periprocedural risk) or subsequent ipsilateral stroke up to 10 years after randomization (postprocedural risk). 

In patients who underwent CEA, 129 periprocedural and 55 postprocedural outcome events occurred, compared with 206 periprocedural and 57 postprocedural outcome events in those who underwent CAS. [13] After the periprocedural period, annual rates of ipsilateral stroke per person-year were 0.60% for CEA and 0.64% for CAS. Overall, the combined periprocedural and postprocedural risks favored CEA; treatment differences at 1, 3, 5, 7, and 9 years ranged from 2.8% to 4.1%. However, the similarity in postprocedural rates suggested that improvements in the periprocedural safety of CAS could yield outcomes similar to those of CEA in the future.

North American Symptomatic Carotid Endarterectomy Trial Collaborators., Barnett HJM, Taylor DW, Haynes RB, Sackett DL, Peerless SJ, et al. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991 Aug 15. 325 (7):445-53. [Medline].

Stroke facts. Centers for Disease Control and Prevention. Available at https://www.cdc.gov/stroke/facts.htm. September 6, 2017; Accessed: February 21, 2019.

Young B, Moore WS, Robertson JT, Toole JF, Ernst CB, Cohen SN, et al. An analysis of perioperative surgical mortality and morbidity in the asymptomatic carotid atherosclerosis study. ACAS Investigators. Asymptomatic Carotid Atherosclerosis Study. Stroke. 1996 Dec. 27 (12):2216-24. [Medline].

Mas JL, Trinquart L, Leys D, Albucher JF, Rousseau H, Viguier A, et al. Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial. Lancet Neurol. 2008 Oct. 7 (10):885-92. [Medline].

Wiesmann M, Schöpf V, Jansen O, Brückmann H. Stent-protected angioplasty versus carotid endarterectomy in patients with carotid artery stenosis: meta-analysis of randomized trial data. Eur Radiol. 2008 Dec. 18 (12):2956-66. [Medline].

Meier P, Knapp G, Tamhane U, Chaturvedi S, Gurm HS. Short term and intermediate term comparison of endarterectomy versus stenting for carotid artery stenosis: systematic review and meta-analysis of randomised controlled clinical trials. BMJ. 2010 Feb 12. 340:c467. [Medline]. [Full Text].

Gurm HS, Yadav JS, Fayad P, Katzen BT, Mishkel GJ, Bajwa TK, et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med. 2008 Apr 10. 358 (15):1572-9. [Medline]. [Full Text].

Illuminati G, Ricco JB, Caliò F, Pacilè MA, Miraldi F, Frati G, et al. Short-term results of a randomized trial examining timing of carotid endarterectomy in patients with severe asymptomatic unilateral carotid stenosis undergoing coronary artery bypass grafting. J Vasc Surg. 2011 Oct. 54 (4):993-9; discussion 998-9. [Medline].

Brown K, Itum DS, Preiss J, Duwayri Y, Veeraswamy RK, Salam A, et al. Carotid artery stenting has increased risk of external carotid artery occlusion compared with carotid endarterectomy. J Vasc Surg. 2015 Jan. 61 (1):119-24. [Medline].

Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010 Jul 1. 363 (1):11-23. [Medline]. [Full Text].

Hill MD, Brooks W, Mackey A, Clark WM, Meschia JF, Morrish WF, et al. Stroke after carotid stenting and endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Circulation. 2012 Dec 18. 126 (25):3054-61. [Medline].

Hye RJ, Mackey A, Hill MD, Voeks JH, Cohen DJ, Wang K, et al. Incidence, outcomes, and effect on quality of life of cranial nerve injury in the Carotid Revascularization Endarterectomy versus Stenting Trial. J Vasc Surg. 2015 May. 61 (5):1208-14. [Medline].

Brott TG, Calvet D, Howard G, Gregson J, Algra A, Becquemin JP, et al. Long-term outcomes of stenting and endarterectomy for symptomatic carotid stenosis: a preplanned pooled analysis of individual patient data. Lancet Neurol. 2019 Feb 6. [Medline].

van Engelen A, Wannarong T, Parraga G, Niessen WJ, Fenster A, Spence JD, et al. Three-dimensional carotid ultrasound plaque texture predicts vascular events. Stroke. 2014 Sep. 45 (9):2695-701. [Medline].

Canadian Cooperative Study Group. A randomized trial of aspirin and sulfinpyrazone in threatened stroke. N Engl J Med. 1978 Jul 13. 299 (2):53-9. [Medline].

[Guideline] Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK, et al. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011 Sep. 54 (3):e1-31. [Medline].

Kato T, Sakai H, Takagi T, Nishimura Y. Cilostazol prevents progression of asymptomatic carotid artery stenosis in patients with contralateral carotid artery stenting. AJNR Am J Neuroradiol. 2012 Aug. 33 (7):1262-6. [Medline].

Orrapin S, Rerkasem K. Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database Syst Rev. 2017 Jun 7. 6:CD001081. [Medline].

Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004 May 8. 363 (9420):1491-502. [Medline].

National coverage determination (NCD) for percutaneous transluminal angioplasty (PTA) (20.7). Centers for Medicare and Medicaid Services. Available at https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?ncdid=201. March 11, 2013; Accessed: February 21, 2019.

Moore WS, Popma JJ, Roubin GS, Voeks JH, Cutlip DE, Jones M, et al. Carotid angiographic characteristics in the CREST trial were major contributors to periprocedural stroke and death differences between carotid artery stenting and carotid endarterectomy. J Vasc Surg. 2016 Apr. 63 (4):851-858.e1. [Medline].

Lal BK, Beach KW, Roubin GS, Lutsep HL, Moore WS, Malas MB, et al. Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial. Lancet Neurol. 2012 Sep. 11 (9):755-63. [Medline].

Jake F Hemingway, MD Resident Physician in Integrated Vascular Surgery, Department of Surgery, University of Washington School of Medicine

Jake F Hemingway, MD is a member of the following medical societies: Society for Vascular Surgery

Disclosure: Nothing to disclose.

Niten Singh, MD, FACS Associate Professor of Surgery, University of Washington School of Medicine; Director of Vascular Limb Preservation, Vascular Surgery Clinic at Harborview

Niten Singh, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Society for Vascular Surgery

Disclosure: Nothing to disclose.

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Surgical Association, Pacific Coast Surgical Association, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Western Vascular Society

Disclosure: Nothing to disclose.

April L Rodriguez, MD, MS Senior Resident, Integrated Vascular Surgery Residency, Department of Surgery, University of Washington School of Medicine

April L Rodriguez, MD, MS is a member of the following medical societies: American College of Surgeons, Society for Clinical Vascular Surgery, Vascular and Endovascular Surgery Society

Disclosure: Nothing to disclose.

David L Gillespie, MD, FACS, RVT, DMCC, COL, MC USA Chief and Program Director, Vascular Surgery Service, Walter Reed Army Medical Center; Professor of Surgery, Uniformed Services University of the Health Sciences; Vascular Surgery Consultant, Office of the US Army Surgeon General

David L Gillespie, MD, FACS, RVT, DMCC, COL, MC is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Venous Forum, Eastern Vascular Society, Society for Vascular Surgery, and Southern Association for Vascular Surgery

Disclosure: Nothing to disclose.

James M Goff, MD Assistant Chief, Department of Surgery, Walter Reed Army Medical Center; Assistant Professor, F Department of Surgery, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences

James M Goff, MD is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Sean D O’Donnell, MD Director, Department of Surgery, Section of Vascular and Endovascular Surgery, Washington Hospital Center

Sean D O’Donnell, MD is a member of the following medical societies: American College of Surgeons and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Atherosclerotic Disease of the Carotid Artery

Research & References of Atherosclerotic Disease of the Carotid Artery|A&C Accounting And Tax Services
Source