carotid artery disease, carotid occlusive disease
TRANSCRIPT
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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