Carotid Artery Stenosis Nature of the Problem Approximately

Carotid Artery Stenosis

Nature of the Problem • Approximately 750, 000 strokes per year • Third-leading cause of death • 1/3 die within 30 days • The principal cause of long-term disability • 1/3 left with permanent disability • 80% are ischemic (lack of blood flow rather than bleeding into brain) • ¾ of these come from carotid distribution • 20 -30% come from carotid stenosis in neck or chest • Percentage changes SIGNIFICANTLY with different ethnicities

Not just atherosclerosis that can cause problems • Fibromuscular dysplasia • Trauma • Carotid dissection

Causes • Up to 3% of those over the age of 65 have a carotid stenosis (blocked artery) • Specific Risk factors are similar to heart disease • • • Age Male sex History of smoking High blood pressure High cholesterol Diabetes

How do you find a carotid stenosis • Physical exam • A bruit is a soft “whooshing” sound that can be heard with a stethoscope • Only 56% sensitive in determining a stenosis • Ultrasound • Inexpensive • Accurate • Quick and non-invasive • CT scan • MRA • Invasive angiography (carries risk of stroke)

When is a carotid stenosis felt risky • Risk of stroke: 0. 5 -1. 0% annually for stenosis >50% • Strokes from carotid stenosis is preceded by TIA in 50 -75% of patients. • Does NOT include lethal or disabling strokes • “High Risk” stenoses • Evidence of stroke without symptoms on MRI • Features on ultrasound (such as ulceration) • Limited brain reserve (possible role of transcranial doppler)

Can carotid stenosis cause problems other than stroke? • Mini Strokes (also called TIA) • Sudden blindness in one eye (called Amaurosis Fugax) • Some evidence of cognitive decline • Unlikely to be the cause of vertigo or dizziness

What are the options • Medical management • Surgery (called carotid endarterectomy) • May be performed with patient asleep or with regional anesthesia • Stent (also called endovascular) • May be performed from groin or arm approach • Hybrid (called TCAR) • Performed with incision above clavicle for direct stent placement

Current Medical Optimization • Statin Therapy (cholesterol) • Antiplatelet Therapy • Blood Pressure Control • Lifestyle modification • • • Smoking cessation (#1 preventable cause of death) Limited alcohol consumption Weight control Regular aerobic physical activity Mediterranean diet

2014 American Heart Association/American Stroke Association Guidelines • Prescribed ASA and statin • Repeat duplex yearly in those patients with greater than 50% stenosis • Consider surgery for those patients with more than 70 percent stenosis with low-risk surgeon and center

When to operate if no symptoms • Life expectancy > 5 years • >80 percent carotid stenosis without symptoms • >70 percent carotid stenosis with symptoms PROVIDED: Peri-operative risk of stroke and death is less than 3 percent for the SURGEON AND CENTER (less than 6% for patients with symptoms)

Where do these numbers come from Largest trials show absolute risk reduction of surgery as 3% over 3 years • VA trial – 444 men • ACAS trial- 1662 adults • ACST trial- 3120 adults • Half of all strokes were fatal or disabling • Only 650 patients were 75 or older (benefit uncertain for that group) • As opposed to symptomatic stenosis, greater degree of stenosis is NOT associated with increase risk

Carotid Disease in those scheduled for other operations • Neurological Complications are second greatest cause of morbidity and mortality following cardiac surgery (e. g. stroke) • HOWEVER, no large trials examine carotid endarterectomy in those undergoing heart bypass • Carotid stenosis in those undergoing general surgery operations • less than 0. 5% (up to 1% if there is carotid bruit)

Increased risk factors for poor outcomes with surgery • Low patient volume (less than 3 cases every 2 years) • Greater number of years since latest physician licensure • There is evidence that specialty of surgeons matters (improved with vascular surgeons over general surgeons) • • Older patient age (>80) Severe heart disease Severe lung disease Severe kidney disease Severe blockage of other carotid artery Long stenosis (extending above angle of jaw) Some evidence that women do worse than men General deconditioning

Contraindications against surgery • Prior neck irradiation or radical neck dissection • Presence of tracheostomy • Vocal cord paralysis on side OPPOSITE surgical one • Brain aneurysm (avoid surgery or stent if >7 mm aneurysm)

What about stenting • Combining results of 5 randomized trials • 6526 patients • Risk of stroke during stent (3. 31%) • Risk of stroke during surgery (1. 05%) • CREST trial • 2502 patients • Combined risk of stroke, heart attack, or death was similar between stent and surgery at 30 days and at 10 years, BUT • Risk of stroke or death within 30 days was greater in stenting group (4. 4 vs 2. 3%) • Risk of heart attack was lower in stenting group (1. 1 vs 2. 3%)

Specific subgroups • Older patients do worse with stenting than surgery • Patients with severe kidney disease do worse with stenting than surgery • 3 x as many “microemboli” during stenting than during surgery

Hybrid Approach (TCAR) • TCAR avoids wire manipulation of aorta by direct access of carotid artery at base of neck for stent • Performed through incision at base of neck • Reverses flow in carotid artery to limit debris

• Bisdas T, Egorova N, Moskowitz AJ. The impact of gender on in-hospital outcomes after carotid endarterectomy or stenting. Eur J Vasc Endovasc Surg. 2012; 44: 244. • Sardar P, Chatterjee S, Aronow HD, et al. Carotid Artery Stenting Versus Endarterectomy for Stroke Prevention: A Meta-Analysis of Clinical Trials. J Am Coll Cardiol 2017; 69: 2266. • Barnett H, Taylor D, Eliasziw M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Colaborators. N Endl. J Med. 1998; 339: 1415. • Chaturvedi S, Bruno A, Ffeasny T, et al. Carotid endarterectomy- an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology 2005; 65: 794. • Cohen D, Stolker J, Wang K, et al. Health-related quality of life after carotid stenting versus carotid endarterectomy: results from CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial). J Am Coll Cardiol 2011; 58: 1557.

• Endarterectomy for asymptomatic carotid stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995; 273. 1421. • Hollenbeak C, et al. The impact of surgical specialty on outcomes for carotid endarterectomy. J Surg Res 2010. 595. • Gasparis A, Ricotta L, Cuadra S, et al. High-risk carotid endarterectomy: fact or fiction. J Vasc Surg 2003; 37: 40. • Bennett K, Scarborough J, Shortell C. Predictors of 30 -day postoperative stroke or death after carotid endarterectomy using the 2012 carotid endarterectomy-targeted American College of Surgeons Nathional Surgical Quality Improvement Program database. J Vasc Surg. 2015; 61: 103. • Dorigo W, Pulli R, Marek J, et al. Carotid endarterectomy in female patients. J Vasc Surg. 2009; 50: 1301.

Prepared By The Eastern Vascular Society Ad-Hoc Committee for Patient Education Branding and Outreach. Richard W. Schutzer, MD Columbia University Medical Center