Carotid Stenosis

John R. Martinelli, OD, FAAOMD Candidate, SGUSOM 14’Newark Beth Israel Medical CenterDepartment of SurgeryJuly 23, 2013

HPI

• 77yo F presents to ED via EMS on 7/10/13

• CC: Extreme Difficulty Breathing & Sweating

• Intubation by EMS

• Unknown Systemic Hx

ED Exam

• Vitals: 98.5, 77, 16, 237/94, 100% (Intub)

• Sedation via Versed (Midazolam)

• CXR: Bilateral Pulmonary Edema

• ECG: LVH

Labs

• WBC: 12.7 (4.5 – 11.0)

• Na: 146 (135 – 145)

• K: 3.2 (3.5 – 5.1)

• PT: 10 (11 – 15)

Assessment/Plan

• LVH with CHF and Pulmonary Edema/Respiratory Failure - Secondary to probable uncontrolled chronic HTN.

• Continue Intubation/VentDiuresis with LasixMax Anti-HTN TxTroponinsStress ECG

IP @ 4 days

• BP 150/40• Stress ECG (Dobutamine)

(-) Ischemia• Troponins (-)• BUN: 28 (7 – 18)

Cr: 1.36 (0.6 – 1.2)

• …Overall Improvement…Discharge?

Carotid Bruit• Right Carotid Bruit discovered IP Day 4

• Stat Doppler US -> 80 – 99% Stenosis R

• Additional Meds: Asa + Statin

• No Associated Neuro Symptoms

• Px Scheduled 7/22/13 SDS R CEA

Imaging

Carotid Doppler

Carotid Doppler

Carotid Doppler

Carotid Doppler

Carotid Stenosis Risks• Atherosclerotic Factors

-Hypertension-Diabetes-Hyperlipidemia/Hypercholesterolemia-Obesity-Smoking-EtOH-Carotid Bifurcation

• CAD

• LVH!

CAD <-> CAS

J Am Coll Cardiol. 2011;57(7):779-783. doi:10.1016/j.jacc.2010.09.047

The severity of CAS and the extent of coronary artery disease (CAD) were significantly correlated (r = 0.255, p < 0.001). Independent predictors of severe CAS defined by PSV were the presence of left-main or 3-vessel CAD, increasing age, a history of stroke, smoking status, and diabetes mellitus.

LVH -> CAS?

Heart and Vessels May 2013, Volume 28, Issue 3, pp 277-283

This study shows that the presence of LVH and higher EAT thickness together improves prediction of CPs in hypertensive patients with 0–1 risk factor and that those with ≥2 RFs show high prevalence of CPs independently of LVH and/or EAT.

CAS Signs/Symptoms

• Asymptomatic -> -> -> TIA -> -> -> CVA

• Neurologic Deficits

-Dependent on Path of Emboli-Contalateral Hemiparesis/Paralysis-Contralateral Sensory Deficits-Aphasia (Afluent vs. Fluent)-Visual Field Defect(s)-Amaurosis Fugax

Hollenhorst Plaque

Hollenhorst Plaque

Non-Arteritic Anterior Ischemic Optic Neuropathy

Non-Arteritic Anterior Ischemic Optic Neuropathy

Asymmetric and/or Normal Tension Glaucoma

Carotid Endarterectomy• Indications

- Symptomatic

One or more transient ischemic attacks (TIAs) in the preceding 6 months and carotid artery stenosis exceeding 50%

Ipsilateral TIA and carotid artery stenosis exceeding 70%, combined with required coronary artery bypass grafting (CABG)

Progressive stroke and carotid artery stenosis exceeding 70%

Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. Aug 15 1991;325(7):445-53.

- Asymptomatic

Good Risk Pxs with > 60% Stenosis

Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA. May 10 1995;273(18):1421-8.

Medical ManagementMay 7 issue of the Annals of Internal MedicineTufts Medical Center, Boston, Massachusetts.

"The medical management of patients with asymptomatic carotid stenosis has improved significantly over the past 20 years, with stroke rates having come down markedly," coauthor David E. Thaler, MD, PhD, commented to Medscape Medical News. "While there may be a role for invasive approaches such as stenting and endarterectomy in high-risk patients, it is not clear if these interventions are superior to medical therapy in the modern era; more work is needed to better identify high-risk patients and to test the interventional approaches in this group."

Endarterectomy Exposure

Endarterectomy Overview

• Local or General Anesthesia• Careful Dissection (n,a,v)• CCA, ICA, ECA Clamped• ICA Incision• Shunt (Brenner)• Removal of Thrombus• ICA Closure & Removal of Shunt

CEA 7/22/13• Patient tolerated procedure well without

complication.

• PACU monitor Q15min x 4hrs

• IP hourly monitor

• ASA QD

• BP

Other Considerations

• CEA vs Stent?

• Bilateral Surgery?

• Contralateral Stenosis?

• Emergent CEA?