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Carotid artery stenosis surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]; Raviteja Guddeti, M.B.B.S. [3]

Overview

Overview

Carotid endarterectomy and stenting are two methods of surgical treatment for carotid artery stenosis.

Surgery

Surgery

Carotid Revascularization in Patients Undergoing CABG

  • Asymptomatic stenosis:
    • The safety and efficacy of carotid revascularization before or concurrent with myocardial revascularization are not well established.
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 (DO NOT EDIT)[1]

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 (DO NOT EDIT)[1]

Selection of Patients for Carotid Revascularization (DO NOT EDIT)[1]

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 (Carotid Endarterectomy) if the diameter of the lumen of the ipsilateral internal carotid artery is reduced more than 70% as documented by noninvasive imaging[2][3] (Level of Evidence: A) or more than 50% as documented by catheter angiography[2][3][4] (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%.[5] (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%.[3][6][7][8][9] (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.[4][10][6][11][12][13] (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.[5][14][15][16][17][18](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.[7][19][20][21] (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.[22] (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.[5] (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.[16][17][16][7][19][20][8][23][24] (Level of Evidence: B) ”

Periprocedural Management of Patients Undergoing Carotid Endarterectomy (DO NOT EDIT)[1]

Class I
“1. Aspirin (81 to 325 mg daily) is recommended before CEA and may be continued indefinitely postoperatively.[25][26] (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.[27][28][29] (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.[30][31] (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.[32] (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) ”

Management of Patients Undergoing Carotid Artery Stenting (DO NOT EDIT)[1]

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.[33][34] (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) ”

Management of Patients Experiencing Restenosis After Carotid Endarterectomy or Stenting (DO NOT EDIT)[1]

Class III (Harm)
“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) ”

Carotid Artery Evaluation and Revascularization Before Cardiac Surgery (DO NOT EDIT)[1]

Class IIa
“1. Carotid duplex ultrasound screening is reasonable before elective coronary artery bypass graft (CABG) surgery in patients older than 65 years of age and in those with left main coronary artery stenosis, PAD, a history of cigarette smoking, a history of stroke or TIA, or carotid bruit. (Level of Evidence: C) ”
“2.Carotid revascularization by CEA or CAS with embolic protection before or concurrent with myocardial revascularization surgery is reasonable in patients with greater than 80% carotid stenosis who have experienced ipsilateral retinal or hemispheric cerebral ischemic symptoms within 6 months. (Level of Evidence: C) ”
Class IIb
“1. In patients with asymptomatic carotid stenosis, even if severe, the safety and efficacy of carotid revascularization before or concurrent with myocardial revascularization are not well established. (Level of Evidence: C) ”
References

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 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.
  2. ↑ 2.0 2.1 Barnett HJ, Taylor DW, Eliasziw M; et al. (1998). “Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators”. N. Engl. J. Med. 339 (20): 1415–25. doi:10.1056/NEJM199811123392002. PMID 9811916. Unknown parameter |month= ignored (help)
  3. ↑ 3.0 3.1 3.2 “Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST)”. Lancet. 351 (9113): 1379–87. 1998. PMID 9593407. Unknown parameter |month= ignored (help)
  4. ↑ 4.0 4.1 Rothwell PM, Slattery J, Warlow CP (1996). “A systematic review of the risks of stroke and death due to endarterectomy for symptomatic carotid stenosis”. Stroke. 27 (2): 260–5. PMID 8571420. Unknown parameter |month= ignored (help)
  5. ↑ 5.0 5.1 5.2 Brott TG, Hobson RW, Howard G; et al. (2010). “Stenting versus endarterectomy for treatment of carotid-artery stenosis”. N. Engl. J. Med. 363 (1): 11–23. doi:10.1056/NEJMoa0912321. PMC 2932446. PMID 20505173. Unknown parameter |month= ignored (help)
  6. ↑ 6.0 6.1 “Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study”. JAMA. 273 (18): 1421–8. 1995. PMID 7723155. Unknown parameter |month= ignored (help)
  7. ↑ 7.0 7.1 7.2 Gurm HS, Yadav JS, Fayad P; et al. (2008). “Long-term results of carotid stenting versus endarterectomy in high-risk patients”. N. Engl. J. Med. 358 (15): 1572–9. doi:10.1056/NEJMoa0708028. PMID 18403765. Unknown parameter |month= ignored (help)
  8. ↑ 8.0 8.1 Bates ER, Babb JD, Casey DE; et al. (2007). “ACCF/SCAI/SVMB/SIR/ASITN 2007 clinical expert consensus document on carotid stenting: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (ACCF/SCAI/SVMB/SIR/ASITN Clinical Expert Consensus Document Committee on Carotid Stenting)”. J. Am. Coll. Cardiol. 49 (1): 126–70. doi:10.1016/j.jacc.2006.10.021. PMID 17207736. Unknown parameter |month= ignored (help)
  9. ↑ Barnett HJ (2004). “Carotid endarterectomy”. Lancet. 363 (9420): 1486–7. doi:10.1016/S0140-6736(04)16182-5. PMID 15135590. Unknown parameter |month= ignored (help)
  10. ↑ Hobson RW, Weiss DG, Fields WS; et al. (1993). “Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. The Veterans Affairs Cooperative Study Group”. N. Engl. J. Med. 328 (4): 221–7. doi:10.1056/NEJM199301283280401. PMID 8418401. Unknown parameter |month= ignored (help)
  11. ↑ Gray WA, Hopkins LN, Yadav S; et al. (2006). “Protected carotid stenting in high-surgical-risk patients: the ARCHeR results”. J. Vasc. Surg. 44 (2): 258–68. doi:10.1016/j.jvs.2006.03.044. PMID 16890850. Unknown parameter |month= ignored (help)
  12. ↑ Katzen BT, Criado FJ, Ramee SR; et al. (2007). “Carotid artery stenting with emboli protection surveillance study: thirty-day results of the CASES-PMS study”. Catheter Cardiovasc Interv. 70 (2): 316–23. doi:10.1002/ccd.21222. PMID 17630678. Unknown parameter |month= ignored (help)
  13. ↑ Rothwell PM, Goldstein LB (2004). “Carotid endarterectomy for asymptomatic carotid stenosis: asymptomatic carotid surgery trial”. Stroke. 35 (10): 2425–7. doi:10.1161/01.STR.0000141706.50170.a7. PMID 15331794. Unknown parameter |month= ignored (help)
  14. ↑ Eckstein HH, Ringleb P, Allenberg JR; et al. (2008). “Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial”. Lancet Neurol. 7 (10): 893–902. doi:10.1016/S1474-4422(08)70196-0. PMID 18774746. Unknown parameter |month= ignored (help)
  15. ↑ Chiam PT, Roubin GS, Panagopoulos G; et al. (2009). “One-year clinical outcomes, midterm survival, and predictors of mortality after carotid stenting in elderly patients”. Circulation. 119 (17): 2343–8. doi:10.1161/CIRCULATIONAHA.108.805465. PMID 19380623. Unknown parameter |month= ignored (help)
  16. ↑ 16.0 16.1 16.2 Roubin GS, New G, Iyer SS; et al. (2001). “Immediate and late clinical outcomes of carotid artery stenting in patients with symptomatic and asymptomatic carotid artery stenosis: a 5-year prospective analysis”. Circulation. 103 (4): 532–7. PMID 11157718. Unknown parameter |month= ignored (help)
  17. ↑ 17.0 17.1 Zahn R, Ischinger T, Hochadel M; et al. (2007). “Carotid artery stenting in octogenarians: results from the ALKK Carotid Artery Stent (CAS) Registry”. Eur. Heart J. 28 (3): 370–5. doi:10.1093/eurheartj/ehl421. PMID 17158826. Unknown parameter |month= ignored (help)
  18. ↑ Ederle J, Dobson J, Featherstone RL; et al. (2010). “Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial”. Lancet. 375 (9719): 985–97. doi:10.1016/S0140-6736(10)60239-5. PMC 2849002. PMID 20189239. Unknown parameter |month= ignored (help)
  19. ↑ 19.0 19.1 Gray WA, Yadav JS, Verta P; et al. (2007). “The CAPTURE registry: results of carotid stenting with embolic protection in the post approval setting”. Catheter Cardiovasc Interv. 69 (3): 341–8. doi:10.1002/ccd.21050. PMID 17171654. Unknown parameter |month= ignored (help)
  20. ↑ 20.0 20.1 Yadav JS, Wholey MH, Kuntz RE; et al. (2004). “Protected carotid-artery stenting versus endarterectomy in high-risk patients”. N. Engl. J. Med. 351 (15): 1493–501. doi:10.1056/NEJMoa040127. PMID 15470212. Unknown parameter |month= ignored (help)
  21. ↑ Harrod-Kim P, Kadkhodayan Y, Derdeyn CP, Cross DT, Moran CJ (2005). “Outcomes of carotid angioplasty and stenting for radiation-associated stenosis”. AJNR Am J Neuroradiol. 26 (7): 1781–8. PMID 16091530. Unknown parameter |month= ignored (help)
  22. ↑ Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ (2004). “Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery”. Lancet. 363 (9413): 915–24. doi:10.1016/S0140-6736(04)15785-1. PMID 15043958. Unknown parameter |month= ignored (help)
  23. ↑ Safian RD, Bacharach JM, Ansel GM, Criado FJ (2004). “Carotid stenting with a new system for distal embolic protection and stenting in high-risk patients: the carotid revascularization with ev3 arterial technology evolution (CREATE) feasibility trial”. Catheter Cardiovasc Interv. 63 (1): 1–6. doi:10.1002/ccd.20155. PMID 15343559. Unknown parameter |month= ignored (help)
  24. ↑ White CJ, Iyer SS, Hopkins LN, Katzen BT, Russell ME (2006). “Carotid stenting with distal protection in high surgical risk patients: the BEACH trial 30 day results”. Catheter Cardiovasc Interv. 67 (4): 503–12. doi:10.1002/ccd.20689. PMID 16548004. Unknown parameter |month= ignored (help)
  25. ↑ “A randomized trial of aspirin and sulfinpyrazone in threatened stroke. The Canadian Cooperative Study Group”. N. Engl. J. Med. 299 (2): 53–9. 1978. doi:10.1056/NEJM197807132990201. PMID 351394. Unknown parameter |month= ignored (help)
  26. ↑ Taylor DW, Barnett HJ, Haynes RB; et al. (1999). “Low-dose and high-dose acetylsalicylic acid for patients undergoing carotid endarterectomy: a randomised controlled trial. ASA and Carotid Endarterectomy (ACE) Trial Collaborators”. Lancet. 353 (9171): 2179–84. PMID 10392981. Unknown parameter |month= ignored (help)
  27. ↑ “A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee”. Lancet. 348 (9038): 1329–39. 1996. PMID 8918275. Unknown parameter |month= ignored (help)
  28. ↑ Mohr JP, Thompson JL, Lazar RM; et al. (2001). “A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke”. N. Engl. J. Med. 345 (20): 1444–51. doi:10.1056/NEJMoa011258. PMID 11794192. Unknown parameter |month= ignored (help)
  29. ↑ Bhatt DL, Fox KA, Hacke W; et al. (2006). “Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events”. N. Engl. J. Med. 354 (16): 1706–17. doi:10.1056/NEJMoa060989. PMID 16531616. Unknown parameter |month= ignored (help)
  30. ↑ AbuRahma AF, Robinson PA, Saiedy S, Richmond BK, Khan J (1999). “Prospective randomized trial of bilateral carotid endarterectomies: primary closure versus patching”. Stroke. 30 (6): 1185–9. PMID 10356097. Unknown parameter |month= ignored (help)
  31. ↑ Bond R, Rerkasem K, AbuRahma AF, Naylor AR, Rothwell PM (2004). “Patch angioplasty versus primary closure for carotid endarterectomy”. Cochrane Database Syst Rev (2): CD000160. doi:10.1002/14651858.CD000160.pub2. PMID 15106145.
  32. ↑ LaMuraglia GM, Stoner MC, Brewster DC; et al. (2005). “Determinants of carotid endarterectomy anatomic durability: effects of serum lipids and lipid-lowering drugs”. J. Vasc. Surg. 41 (5): 762–8. doi:10.1016/j.jvs.2005.01.035. PMID 15886657. Unknown parameter |month= ignored (help)
  33. ↑ Garg N, Karagiorgos N, Pisimisis GT; et al. (2009). “Cerebral protection devices reduce periprocedural strokes during carotid angioplasty and stenting: a systematic review of the current literature”. J. Endovasc. Ther. 16 (4): 412–27. doi:10.1583/09-2713.1. PMID 19702342. Unknown parameter |month= ignored (help)
  34. ↑ Andziak P (2006). “[Commentary to the articles: SPACE Collaborative Group. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 2006; 368: 1239-47. Mas JL, Chatellier G, Beyssen B, et al. EVA-3S Investigators. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006; 355: 1660-71]”. Kardiol Pol (in Polish). 64 (12): 1458–60, discussion 1460–1. PMID 17206550. Unknown parameter |month= ignored (help)

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