Current indications & therapies for Carotid Artery Stenosis
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Current indications & therapies for Carotid Artery Stenosis

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Brought to you from the caring and expert staff of the beautiful modern Vascular Center at Sisters' of Charity Hospital of Buffalo, 2157 Main Street Buffalo, New York 14214 USA

Brought to you from the caring and expert staff of the beautiful modern Vascular Center at Sisters' of Charity Hospital of Buffalo, 2157 Main Street Buffalo, New York 14214 USA

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Current indications & therapies for Carotid Artery Stenosis Presentation Transcript

  • 1. Carotid Artery Stenosis & Stroke Current Indications and Therapies
  • 2. Stroke Facts
    • Every 45 seconds someone in the USA has a stroke
    • Annually 46,000 more women than men have a stroke
    • 1 out of every 15 deaths in the USA are because of a stroke
    • Mean lifetime cost of ischemic stroke is $140,078
  • 3. What is Carotid Artery Disease?
    • A type of peripheral arterial disease
    • Narrowing in the carotid artery
    • Atherosclerotic plaque accumulates over time
    • Most frequently observed at the carotid bifurcation
  • 4. A Risk Factor for Stroke
    • Plaque or clot breaks off from the carotid & blocks a smaller artery in the brain
    • Narrowing of the carotids due to plaque build-up
    • A clot becomes wedged in a carotid artery narrowed by plaque
  • 5. Stroke Symptoms
    • Sudden weakness of face/arm/leg, especially on one side of the body
    • Abrupt onset of confusion, trouble speaking or understanding
    • Sudden double vision or vision problems
    • Abrupt onset of dizziness/loss of balance or coordination
    • Sudden and severe headache
  • 6. Carotid Artery Disease Symptoms
    • Bruit in the affected carotid artery
    • TIA
    • Amarurosis Fugax – temporary blindness in one eye
    • IMPORTANT: Patients may NOT have any symptoms
  • 7. Diagnostic Tools for Carotid Artery Disease
    • H & P
    • Duplex Ultrasound of the carotids
    • Computed Tomographic Angiography (CTA) of the neck
    • Magnetic Resonance Angiography (MRA) of the carotids
    • Carotid Angiography
  • 8. Duplex Ultrasound Advantages
    • Non-invasive and painless
    • Widely available
    • Locate and determine degree of lesion stenosis
    • Post-procedure follow-up tool
    • May give information on the plaque characteristics
  • 9. Duplex Ultrasound - Disadvantages
    • Operator dependent results
    • Tendency for overestimating lesion
    • Calcium may obscure lesion
  • 10. CTA - Advantages
    • More precise than a MRA or ultrasound
    • Safer
    • Less time consuming
    • Less invasive that conventional angiography
  • 11. CTA - Disadvantages
    • Contrast Nephrotoxicity
    • Allerigc reaction to contrast
    • More complex and expensive than ultrasound
    • Not widely used compared to ultrasound
    • Patient motion affects image quality
  • 12. MRA - Advantages
    • Non-invasive and safer than carotid angiogram
    • No intra-arterial catheterization
    • No exposure to x-rays
    • Procedure and recovery times are shorter that carotid angiography
    • Allergic reaction to contrast is minimal
    • Kidney damage from contrast is rare
  • 13. MRA - Disadvantages
    • Claustrophobic patients will have to be pre-medicated
    • Interaction with pacemakers and other metallic implants
    • Does not image calcium well
    • Very tight stenosis may be difficult to distinguish from an occulsion
  • 14. Carotid Angiography - Advantages
    • Clear & accurate vessel visualization
    • Diagnosis & treatment in a single procedure
  • 15. Carotid Angiography - Disadvantages
    • Risk of stroke associated with carotid angiogram
    • Relatively expensive and invasive
    • Potential for allergic reaction to the dye
    • nephrotoxic
  • 16. Dr. Anain’s diagnostics
    • Carotid duplex
    • If the patient is at moderate risk for Carotid Artery Endarterectomy then a MRA/CTA
    • If the patient is high risk for Carotid Artery Endarterectomy then: Carotid Angiogram
  • 17. Treatment Modalities
    • Medical Therapy
    • Carotid Endarterectomy (CEA)
    • Carotid Artery Stenting (CAS)
  • 18. Medical Treatment
    • To reduce the risk of future stroke:
    • Control hypertension, diabetes, and weight
    • Stop smoking
    • Lower cholesterol
    • Increase exercise
  • 19. Medical Treatment
    • Serial carotid duplex ultrasounds to monitor the disease
    • Antiplatelet – Aspirin, Plavix
    • Anticoagulation – coumadin
    • Statin
  • 20. CEA – Carotid Endarterectomy
    • To reduce the risk of stroke
    • Surgically remove plaque
    • Arteriotomy at the stenotic section of the carotid
    • Plaque is manually removed
    • Closure of arteriotomy
  • 21. CEA Advantages
    • Proven effective in low surgical risk patients
    • Safe and effective (with an experienced surgeon)
    • Decreases the risk of stroke
  • 22. CEA - Disadvantages
    • Surgery and neck incision therefore longer recovery time
    • Risk with general anesthesia
    • Potential for emboli and cause stroke
    • Cranial nerve palsy (X and XII)
    • Infection
    • Unproven indication in high surgical risk candidates
  • 23. CAS – Carotid Artery Stenting
    • Endovascular stent placement via stab wound in the groin
    • For plaque stabilization to reduce the risk of future stroke
  • 24. CAS
    • Use of embolic protection placed in carotid artery to reduce the chance of peri-procedure complications (throwing a clot into brain)
    • Placement of a self-expanding stent to trap or exclude the plaque
    • Devices (embolic protection) and catheters are removed while the stent remains and the access site (groin) bleeding is managed with a vascular closure device in the wound and a pressure dressing
  • 25. CAS - Advantages
    • If patient has contraindication for a CEA (already had a CEA, multiple diseases and a high surgical risk)
    • Stabilizes the plaque to minimize risk of embolization
    • Avoids the risk of cranial nerve damage
    • Does not require general anesthesia
    • Option for patients
  • 26. CAS - Disadvantages
    • Potential for embolization resulting in stroke
    • Not all patients are suitable for stenting:
    • Severe aortic arch and supra-aortic vessel tortuosity
    • Thrombus
    • String sign present
    • Patients with very long & severe lesions
    • Heavy all around calcification of the artery
  • 27. Carotid Endarterectomy-outcomes
    • Adequate cerebral blood flow
    • Pain controlled
    • Evidence of normal wound healing
    • Know ways to slow the progression of atherosclerosis
    • Know S&S to report
    • Understand follow-up care
  • 28. Nursing Diagnoses
    • Pre-op ineffective cerebral perfusion
    • Post-op potential complications: cerebral ischemia, respiratory distress, cranial nerve damage (facial VII, hypoglossal XII, glossopharyngeal IX, Vagus X, Accessory XI)
    • Deficient knowledge, ineffective therapeutic regimen management, or ineffective health maintenance
  • 29. Nursing DX: Ineffective Tissue Perfusion Cerebral
    • Partial or complete occulsion of the carotid artery by atherosclerotic plaque and/or thrombus
    • A cerebral embolus associated with dislodgment of atherosclerotic plaque or a thrombus from the carotid artery
  • 30. Nursing DX: Ineffective Tissue Perfusion Cerebral – Desired Outcome
    • Maintain adequate cerebral tissue perfusion as evidenced by:
    • Mentally alert and orientates
    • Absence of dizziness, visual disturbances, and speech impairments
    • Normal motor and sensory function
  • 31. Report Symptoms of Carotid Artery Occlusion and/or cerebral embolization
    • Agitation
    • Lethargy
    • Confusion
    • Dizziness
    • Slurred speech
    • Expressive aphasia
    • Paresthesias
  • 32. Measures to maintain adequate cerebral tissue perfusion
    • Administer antiplatelet agents to prevent new or extended thrombus formation and further occulsion of the carotid artery
    • Avoid activities that create a Valsalva response (strain with BM, holding breath while moving up in bed)
    • Prevent HTN to reduce risk of cerebral embolism by reduce stress, give antihypertensives
  • 33. If Symptoms of decreased cerebral perfusion occur
    • Maintain of bed rest
    • Head of bed flat unless contraindicated
    • Anticoagulants (IV Heparin, Lovenox, warfarin
    • Provide emotional support to patient and family Symptoms usually necessitates postponement of planned surgery
  • 34. Potential Complications of Carotid Endarterectomy – Cerebral Ischemia
    • Prolonged artery clamp time during surgery and/or vasospasm associated w/clamping and manipulation of cerebral vessels
    • Hypotension associated w/hypovolemia from blood loss and IV Dextran commonly used
    • Embolization during or after surgery and/or formation of a thrombus at surgical site
  • 35. Potential Complications of Carotid Endarterectomy – Respiratory Distress
    • Airway obstruction associated w/tracheal compression which can occur as a result of inflammation,
    • edema,
    • and/or hematoma formation in the surgical area of the neck
  • 36. Potential Complications of Carotid Endarterectomy – Cranial Nerve Damage
    • Facial VII, hypoglossal XII, glossopharyngeal IX, Vagus X, and/or accessory nerves XI
    • Related to surgical trauma and/or compression of the nerves as a result of inflammation, edema, and/or hematoma formation
    • Observe for TIA or stroke symptoms
  • 37. Nursing Actions to maintain adequate cerebral blood flow – post op
    • Report S&S of excessive site bleeding (new or expanding hematoma, continued bright red bleeding from incision and wound drain
    • Report decreasing Hgb levels
    • Report S&S of hypovolemic shock
    • Report S&S cerebral ischemia TIA/stroke symptoms
  • 38. Implement measures to prevent cerebral ischemia – reduce pressure on carotid vessels
    • Reduce operative site inflammation and/or edema: HOB up, ice pack to incision as ordered
    • Maintain patency of wound drain: free of kinks and emptied as often as necessary
    • Instruct pt to avoid turning head abruptly or hyperextending neck to reduce stress on suture line and prevent a hematoma
  • 39. Implement measures to prevent cerebral ischemia – reduce pressure on carotid vessels
    • Caution pt to avoid activities that create a Valsalva response to prevent dislodgment of exisitng thrombi and reduce stress and bleeding from suture line
    • Maintain blood pressure within a safe range w/ antihypertensives
    • HTN may occur as a result of underlying disease processes or damage to the carotid sinus baroreceptors during surgery
  • 40. Implement measures to prevent cerebral ischemia – reduce pressure on carotid vessels
    • Control HTN to prevent rupture of the operative vessel or reduce risk of dislodgment of any existing thrombus
    • To treat hypotension consider sympathomimetics (dopamine) and transfer to ICU if on drip
  • 41. Patient will not experience respiratory distress – assess for & report
    • Increased edema or expanding hematoma in surgical area
    • Deviation of trachea from midline
    • New or increased difficulty swallowing
    • S&S of respiratory distress: restlessness, agitation, rapid and/or labored breathing, stridor, sternocleidomastoid muscle retraction
    • Significant decrease in pulse oximetry results
  • 42. Thank You
    • For your kind attention
    • From:
    • Bridget Foster,RN Christina Palmeri, RN, Tonya Salter, RN, Lana Pasek, NP, the staff of 3 North of Sister’s of Charity Hospital and Paul Anain, MD of the Endovascular and Vascular Center of Western New York