carotid artery disease, carotid occlusive disease

CAROTID ARTERY DISEASE

Carotid Occlusive DiseaseRefrence :Schwartzs Principles of Surgery 10th ed Presented by

Dr Sadatinejad, Seyyed Mohsen,student of Medicine from Iran,Kashan 29/6/2015

Intro.

▪ Atherosclerotic occlusive plaque carotid artery bifurcation

30-60 %↓of all ischemic strokes

this presentation include :EtiologyClinical PresentationDiagnosisManagement (Medical Therapy, Surgical Carotid

Endarterectomy, stenting)

Etiology of Carotid Occlusive Disease

▪ All strokes : 85% Ischemic (CVA)

15% hemorrhagic

▪ Ischemic due to : |arterial occlusion

|proximal arterial stenosis

|poor collateral network

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Epidemiology and Etiology of Carotid Occlusive Disease

Cardiogenic emboli35%

Carotid artery disease

30%

Lacunar10%

Miscellaneous10%

Idiopathic 15%

Common causes of ischemic strokes :

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Carotid bifurcation occlusiveSeparation of flow

↓Intimal injury

↓

↓

↓Atherosclerotic plaque formation

↓

Stenosis↑ turbulent flow↑

↓

Risk of atheroembolization↑

mild (<50%)

moderate (50%–69%)

severe (70%–99%)

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Risk Factor

■ Age ↑

■ male gender

■ Hypertension

■ tobacco smoking

■ diabetes mellitus

■ Homocysteinemia

■ Hyperlipidemia

■ prior history of neurologic symptoms (TIA or stroke)

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Clinical Manifestationsof Cerebral Ischemia

▪ TIA : focal loss of neurologic function, lasting for less than 24 hours.

▪ ↕ Reversible ischemic neurologic deficits

▪ completed stroke : longer than 3 weeks

▪ 3 categories of symptoms:

1.ocular symptoms

2. sensory/motor deficit

3. higher cortical dysfunction

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Clinical Manifestationsof Cerebral Ischemia

1.ocular symptoms

▪ amaurosis fugax ▪ presence of 

Hollenhorst plaques

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Clinical Manifestationsof Cerebral Ischemia

2. sensory/motor deficit

▪ Sudden loss of neurologic function

▪ No seizures or paresthesia

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Clinical Manifestationsof Cerebral Ischemia

3. higher cortical disfunctions

▪ speech and language disturbances (carotid a.

thromboamboli)

▪ dysphasia or aphasia (dominant hemisphere injury)

▪ visuospatial neglect (nondominant hemisphere injury)

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Diagnostic Evaluation

Duplex ultrasonography (screening)

CT-Angiography (CTA)

MR-Angiography (MRA) (no need to contrast agents)

DSA (digital substraction angiography)(invasive/ iodinated contrast)

For evaluation cerebral ischemic changes : CT/ MRI

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Treatment of Carotid Occlusive Disease

The risk of a recurrent ipsilateral stroke in patients with severe carotid stenosis approaches 40%.

stroke prevention :▪ medical treatment ▪ carotid endarterectomy▪ Stenting

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Treatment of Carotid Occlusive Disease4

Carotid Stenosis

Symptomatic(prior ipsilatral stroke or TIA)

mild stenosis

aspirin + clopidogrel

Severe & Moderate stenosis

carotid endarterectomy

(70%–99% ↓ Risk)

Carotid stenting

Asymptomatic

mild & Moderate stenosis

?????controversial

Severe stenosis

carotid endarterectomy

(53% ↓ Relative Risk )

Carotid Endarterectomy versus Stenting

▪ carotid artery stenting : FDA approve in 2004

▪ A recent Cochrane review, before 2006, 1269 patients

▪ Greater risk of stroke and death

▪ Restenosis

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Carotid Endarterectomy versus Stenting4

Carotid Endarterectomy versus Stenting4

Surgical Techniques of Carotid Endarterectomy4

Surgical Techniques of Carotid Endarterectomy4

Surgical Techniques of Carotid Endarterectomy4

Complications of Carotid Endarterectomy

Cerebral ischemia (intraoperative or postoperative events/ Carotid duplex scan )

Acute ipsilateral stroke (intraoperative or postoperative/ due to embolization)

Local complications :

excessive bleeding Postoperative hematoma cranial nerve palsies :marginal

mandibular, vagus, hypoglossal, superior laryngeal, and recurrent laryngeal nerves

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Complications of Carotid Stenting

▪ Embolization and stroke

▪ Restenosis

▪ Bradycardia and hypotension (20%)

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* Carotid Coil and Kink* Fibromuscular Dysplasia* Carotid Artery Dissection* Carotid Artery Aneuarysms* Carotid Body Tumor

Nonatherosclerotic Disease of the Carotid Artery

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