Carotid artery stenosis surgery: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
No edit summary
Line 49: Line 49:
# Embolic protection device (EPD) deployment during CAS can be beneficial to reduce the risk of stroke when the risk of vascular injury is low. (Level of Evidence: C)
# Embolic protection device (EPD) deployment during CAS can be beneficial to reduce the risk of stroke when the risk of vascular injury is low. (Level of Evidence: C)
# Noninvasive imaging of the extracranial carotid arteries is reasonable 1 month, 6 months, and annually after revascularization to assess patency and exclude the development of new or contralateral lesions. Once stability has been established over an extended period, surveillance at extended intervals may be appropriate. Termination of surveillance is reasonable when the patient is no longer a candidate for intervention. (Level of Evidence: C)
# Noninvasive imaging of the extracranial carotid arteries is reasonable 1 month, 6 months, and annually after revascularization to assess patency and exclude the development of new or contralateral lesions. Once stability has been established over an extended period, surveillance at extended intervals may be appropriate. Termination of surveillance is reasonable when the patient is no longer a candidate for intervention. (Level of Evidence: C)
}}
==Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Management of Patients Experiencing Restenosis After Carotid Endarterectomy or Stenting<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 | pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }} </ref> (DO NOT EDIT)==
{{cquote|
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]===
# Reoperative CEA or CAS should not be performed in asymptomatic patients with less than 70% carotid stenosis that has remained stable over time. (Level of Evidence: C)
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
# In patients with symptomatic cerebral ischemia and recurrent carotid stenosis due to intimal hyperplasia or atherosclerosis, it is reasonable to repeat CEA or perform CAS using the same criteria as recommended for initial revascularization. (Level of Evidence: C)
# Reoperative CEA or CAS after initial revascularization is reasonable when duplex ultrasound and another confirmatory imaging method identify rapidly progressive restenosis that indicates a threat of complete occlusion. (Level of Evidence: C)
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]===
# In asymptomatic patients who develop recurrent carotid stenosis due to intimal hyperplasia or atherosclerosis, reoperative CEA or CAS may be considered using the same criteria as recommended for initial revascularization. (Level of Evidence: C)
}}
}}
==Surgery==
==Surgery==

Revision as of 14:51, 2 October 2012

Carotid artery stenosis Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Carotid artery stenosis from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Testing Guidelines

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

CT

MRI

MRA

Echocardiography or Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

ACC/AHA Guideline Recommendations

Diagnostic Testing Guidelines Recommendation

Primary Prevention and Screening Guidelines Recommendations

Secondary Prevention Guidelines Recommendations

Selection of Patients for Carotid Revascularization

Periprocedural Management of Patients Undergoing Carotid Endarterectomy

Management of Patients Undergoing Carotid Artery Stenting

Restenosis After Carotid Endarterectomy or Stenting

Vascular Imaging in Patients With Vertebral Artery Disease

Atherosclerotic Risk Factors in Patients With Vertebral Artery Disease

Occlusive Disease of the Subclavian and Brachiocephalic Arteries

Fibromuscular Dysplasia

Cervical Artery Dissection

Case Studies

Case #1

Carotid artery stenosis surgery On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Carotid artery stenosis surgery

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Carotid artery stenosis surgery

CDC on Carotid artery stenosis surgery

Carotid artery stenosis surgery in the news

Blogs on Carotid artery stenosis surgery

Directions to Hospitals Treating Carotid artery stenosis

Risk calculators and risk factors for Carotid artery stenosis surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Please help WikiDoc by adding more content here. It's easy! Click here to learn about editing.

Overview

Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Selection of Patients for Carotid Revascularization[1] (DO NOT EDIT)

“

Class I

  1. Patients at average or low surgical risk who experience nondisabling ischemic stroke† or transient cerebral ischemic symptoms, including hemispheric events or amaurosis fugax, within 6 months (symptomatic patients) should undergo CEA if the diameter of the lumen of the ipsilateral internal carotid artery is reduced more than 70%‡ as documented by noninvasive imaging (Level of Evidence: A) or more than 50% as documented by catheter angiography (Level of Evidence: B) and the anticipated rate of perioperative stroke or mortality is less than 6%.
  2. CAS is indicated as an alternative to CEA for symptomatic patients at average or low risk of complications associated with endovascular intervention when the diameter of the lumen of the internal carotid artery is reduced by more than 70% as documented by noninvasive imaging or more than 50% as documented by catheter angiography and the anticipated rate of periprocedural stroke or mortality is less than 6%. (Level of Evidence: B)
  3. Selection of asymptomatic patients for carotid revascularization should be guided by an assessment of comorbid conditions, life expectancy, and other individual factors and should include a thorough discussion of the risks and benefits of the procedure with an understanding of patient preferences. (Level of Evidence: C)

Class III

  1. Except in extraordinary circumstances, carotid revascularization by either CEA or CAS is not recommended when atherosclerosis narrows the lumen by less than 50%. (Level of Evidence: A)
  2. Carotid revascularization is not recommended for patients with chronic total occlusion of the targeted carotid artery. (Level of Evidence: C)
  3. Carotid revascularization is not recommended for patients with severe disability caused by cerebral infarction that precludes preservation of useful function. (Level of Evidence: C)

Class IIa

  1. It is reasonable to perform CEA in asymptomatic patients who have more than 70% stenosis of the internal carotid artery if the risk of perioperative stroke, MI, and death is low. (Level of Evidence: A)
  2. It is reasonable to choose CEA over CAS when revascularization is indicated in older patients, particularly when arterial pathoanatomy is unfavorable for endovascular intervention. (Level of Evidence: B)
  3. It is reasonable to choose CAS over CEA when revascularization is indicated in patients with neck anatomy unfavorable for arterial surgery. (Level of Evidence: B)
  4. When revascularization is indicated for patients with TIA or stroke and there are no contraindications to early revascularization, intervention within 2 weeks of the index event is reasonable rather than delaying surgery. (Level of Evidence: B)

Class IIb

  1. Prophylactic CAS might be considered in highly selected patients with asymptomatic carotid stenosis (minimum 60% by angiography, 70% by validated Doppler ultrasound), but its effectiveness compared with medical therapy alone in this situation is not well established. (Level of Evidence: B)
  2. In symptomatic or asymptomatic patients at high risk of complications for carotid revascularization by either CEA or CAS because of comorbidities, the effectiveness of revascularization versus medical therapy alone is not well established. (Level of Evidence: B)
 ”

Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Periprocedural Management of Patients Undergoing Carotid Endarterectomy[1] (DO NOT EDIT)

“

Class I

  1. Aspirin (81 to 325 mg daily) is recommended before CEA and may be continued indefinitely postoperatively. (Level of Evidence: A)
  2. Beyond the first month after CEA, aspirin (75 to 325 mg daily), clopidogrel (75 mg daily), or the combination of low-dose aspirin plus extended-release dipyridamole (25 and 200 mg twice daily, respectively) should be administered for long-term prophylaxis against ischemic cardiovascular events. (Level of Evidence: B)
  3. Administration of antihypertensive medication is recommended as needed to control blood pressure before and after CEA. (Level of Evidence: C)
  4. The findings on clinical neurological examination should be documented within 24 hours before and after CEA. (Level of Evidence: C)

Class IIa

  1. Patch angioplasty can be beneficial for closure of the arteriotomy after CEA.62,63 (Level of Evidence: B)
  2. Administration of statin lipid-lowering medication for prevention of ischemic events is reasonable for patients who have undergone CEA irrespective of serum lipid levels, although the optimum agent and dose and the efficacy for prevention of restenosis have not been established. (Level of Evidence: B)
  3. Noninvasive imaging of the extracranial carotid arteries is reasonable 1 month, 6 months, and annually after CEA to assess patency and exclude the development of new or contralateral lesions. Once stability has been established over an extended period, surveillance at longer intervals may be appropriate. Termination of surveillance is reasonable when the patient is no longer a candidate for intervention. (Level of Evidence: C)
 ”

Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Management of Patients Undergoing Carotid Artery Stenting[1] (DO NOT EDIT)

“

Class I

  1. Before and for a minimum of 30 days after CAS, dual-antiplatelet therapy with aspirin (81 to 325 mg daily) plus clopidogrel (75 mg daily) is recommended. For patients intolerant of clopidogrel, ticlopidine (250 mg twice daily) may be substituted. (Level of Evidence: C)
  2. Administration of antihypertensive medication is recommended to control blood pressure before and after CAS. (Level of Evidence: C)
  3. The findings on clinical neurological examination should be documented within 24 hours before and after CAS. (Level of Evidence: C)

Class IIa

  1. Embolic protection device (EPD) deployment during CAS can be beneficial to reduce the risk of stroke when the risk of vascular injury is low. (Level of Evidence: C)
  2. Noninvasive imaging of the extracranial carotid arteries is reasonable 1 month, 6 months, and annually after revascularization to assess patency and exclude the development of new or contralateral lesions. Once stability has been established over an extended period, surveillance at extended intervals may be appropriate. Termination of surveillance is reasonable when the patient is no longer a candidate for intervention. (Level of Evidence: C)
 ”

Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Management of Patients Experiencing Restenosis After Carotid Endarterectomy or Stenting[1] (DO NOT EDIT)

“

Class III

  1. Reoperative CEA or CAS should not be performed in asymptomatic patients with less than 70% carotid stenosis that has remained stable over time. (Level of Evidence: C)

Class IIa

  1. In patients with symptomatic cerebral ischemia and recurrent carotid stenosis due to intimal hyperplasia or atherosclerosis, it is reasonable to repeat CEA or perform CAS using the same criteria as recommended for initial revascularization. (Level of Evidence: C)
  2. Reoperative CEA or CAS after initial revascularization is reasonable when duplex ultrasound and another confirmatory imaging method identify rapidly progressive restenosis that indicates a threat of complete occlusion. (Level of Evidence: C)

Class IIb

  1. In asymptomatic patients who develop recurrent carotid stenosis due to intimal hyperplasia or atherosclerosis, reoperative CEA or CAS may be considered using the same criteria as recommended for initial revascularization. (Level of Evidence: C)
 ”

Surgery

References

  1. ↑ 1.0 1.1 1.2 1.3 Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL; et al. (2011). "2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery". Circulation. 124 (4): 489–532. doi:10.1161/CIR.0b013e31820d8d78. PMID 21282505.
Retrieved from "https://www.wikidoc.org/index.php?title=Carotid_artery_stenosis_surgery&oldid=764751"