Carotid artery stenosis surgery

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

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Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Selection of Patients for Carotid Revascularization (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 (No Benefit)

"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) 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) "

"2. 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) "

"3. 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 (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) "

"3. 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 (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)

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

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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) 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) 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)

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Surgery

• Carotid endarterectomy (surgical removal of the atheroma)
• Carotid stenting