Management of symptomatic carotid atherosclerotic disease
- Emile R Mohler III, MD
Emile R Mohler III, MD
- Section Editor — Vascular Medicine
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Ronald M Fairman, MD
Ronald M Fairman, MD
- Professor of Surgery and Radiology
- University of Pennsylvania School of Medicine
- Section Editors
- Scott E Kasner, MD
Scott E Kasner, MD
- Section Editor — Stroke
- Professor of Neurology
- University of Pennsylvania School of Medicine
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
The location most frequently affected by carotid atherosclerosis is the carotid bifurcation, often with extension into the proximal internal carotid artery (ie, the origin). Progression of atheromatous plaque at the carotid bifurcation results in luminal narrowing, often accompanied by ulceration. This process can lead to ischemic stroke or transient ischemic attack (TIA) from embolization, thrombosis, or hemodynamic compromise.
Carotid endarterectomy (CEA) is established as safe and effective by randomized controlled trials for reducing the risk of ischemic stroke in both symptomatic and asymptomatic patients with carotid artery atherosclerosis. Advances in medical management and percutaneous carotid angioplasty and stenting (CAS) are proposed alternatives to CEA that may impact the future use of surgical revascularization techniques for carotid disease.
This topic will review the treatment of symptomatic carotid atherosclerotic disease. The management of asymptomatic carotid disease is discussed separately. (See "Management of asymptomatic carotid atherosclerotic disease".)
Other aspects of carotid occlusive disease are reviewed elsewhere. (See "Pathophysiology of symptoms from carotid atherosclerosis" and "Evaluation of carotid artery stenosis" and "Carotid endarterectomy".)
DEFINITION OF SYMPTOMATIC DISEASE
Symptomatic carotid disease is defined as focal neurologic symptoms that are sudden in onset and referable to the appropriate carotid artery distribution (ipsilateral to significant carotid atherosclerotic pathology), including one or more transient ischemic attacks characterized by focal neurologic dysfunction or transient monocular blindness, or one or more minor (nondisabling) ischemic strokes . The definition is contingent on the occurrence of carotid symptoms within the previous six months [1,2]. Thus, although there is no precise time limitation, remote carotid symptoms should not be considered as indicative of "symptomatic" carotid disease.
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- DEFINITION OF SYMPTOMATIC DISEASE
- CAROTID ENDARTERECTOMY
- Method of stenosis measurement
- NASCET trial
- ECST trial
- Pooled analysis
- Perioperative complication rate
- Timing of surgery
- - After mild stroke or TIA
- - After moderate to severe stroke
- - Very early or emergent CEA
- Other factors influencing benefit and risk with CEA
- - Gender
- - Retinal versus hemispheric ischemia
- - Contralateral carotid stenosis or occlusion
- Risk modeling
- CAROTID STENTING
- Randomized trials
- - ICSS
- - SPACE
- - EVA-3S
- - CREST
- - Early trials
- Effect of age
- Stenting in other subgroups
- MEDICAL MANAGEMENT
- RECOMMENDATIONS OF OTHERS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS