Carotid artery disease

CAROTID ARTERY DISEASE
DEPARTMENT OF CARDIAC AND VASCULAR SURGERY
MEDICAL UNIVERSITY PLOVDIV
HRISTO RAHMAN

HRISTO RAHMAN 11/04/20
INTRODUCTION
STROKE IS 3-RD LEADING CAUSE OF DEATH AND LEADING CAUSE OF SERIOUS DISABILITY
AMONG PATIENTS FROM ALL OVER THE WORLD.
APPROX. 15% OF STROKES ARE CAUSED BY PRIMARY HAEMORRHAGE - INTRAPARENCHYMAL
BLEEDING FROM HYPERTENSION
APPROX. 85% OF STROKES HAVE ISCHAEMIC CAUSE:
- 20-30% ARE SECONDARY TO EMBOLI FROM ATHEROSCLEROTIC CEREBROVASCULAR
DISEASE;
- 20% OF PATIENTS WITH >50% STENOSIS OF EXTRA-CRANIAL ARTERIES WERE SHOWN TO
HAVE EMBOLIC EVENTS IN TRANS-CRANIAL DOPPLER STUDIES

INTRODUCTION
MOST COMMON LOCATION FOR
ATHEROSCLEROSIS IN
CEREBROVASCULAR
CIRCULATION IS CAROTID
BIFURCATION
THUS, MANY STROKES ARE
PREVENTABLE WITH CAROTID
INTERVENTION

PATHOPHYSIOLOGY
LEADING CAUSE OF ISCHAEMIC STROKE IN U.S. AND EUROPE IS THE DEVELOPMENT
OF ATHEROSCLEROTIC PLAQUE IN THE EXTRA-CRANIAL ARTERIES
THIS ACCOUNTS FOR:
- 90% OF EXTRA-CRANIAL CEREBROVASCULAR DISEASE;
- 10% - CAUSED BY DISEASE PROCESS: ARTERIITIS AND FIBROMUSCULAR DYSPLASIA

PATHOPHYSIOLOGY
ATHEROSCLEROTIC LESIONS USUALLY OCCUR AT:
- PROXIMAL INTERNAL CAROTID ARTERY (ICA);
- CAROTID BIFURCATION OPPOSITE THE ORIGIN OF THE EXTERNAL
CAROTID ARTERY (ECA)
AFTER DEVELOPMENT OF HAEMODYNAMICALLY SIGNIFICANT
STENOSIS, THE ATHEROSCLEROTIC PLAQUE MAY CAUSE STROKE BY
ONE OF THE FOLLOWING PRINCIPAL MECHANISMS:
- 1. EMBOLISATION OF ATHEROSCLEROTIC PARTICLE;
- 2. THROMBOTIC OCCLUSION;
- 3. HYPOPERFUSION

CLINICAL PRESENTATION
ASYMPTOMATIC PATIENTS WITH HAEMODYNAMICALLY SIGNIFICANT CAROTID ARTERY
DISEASE
DURING ROUTINE PHYSICAL EXAMINATION - AUDIBLE CAROTID BRUIT IN NECK
IN SEVERE CAROTID ARTERY DISEASE, BECAUSE OF MARKEDLY REDUCED BLOOD FLOW,
NO AUDIBLE BRUIT IN NECK MAY BE DETECTED
SCREENING CAROTID DUPLEX ULTRASOUND SHOUL DE PERFORMED IN:
- 1. ASYMPTOMATIC PATIENTS WITH BRUITS;
- 2. HIGH-RISK PATIENTS WITHOUT BRUITS

CLINICAL PRESENTATION
SYMPTOMS OF CAROTID ARTERY
DISEASE INCLUDE:
- 1. TRANSITORY ISCHAEMIC ATTACK (TIA);
- 2. AMAUROSIS FUGAX;
- 3. STROKE

TRANSITORY ISCHAEMIC ATTACK
(TIA)

CAROTID ARTERY DISEASE - CLINICAL PRESENTATION
TRANSITORY ISCHAEMIC ATTACK (TIA)
BRIEF ACUTE LOSS OF FOCAL CEREBRAL FUNCTION, LASTING <24 HOURS
BRIEF ( 2-15 MIN.) AND RAPID ONSET
NO PERSISTENT DEFICIT AFTER TIA
OFTEN MULTIPLE TIAs
LOSS OF FUNCTION LOCALISED TO REGION OF THE BRAIN, SUPPLIED BY ONE
VASCULAR SYSTEM (RIGHT OR LEFT CAROTID ARTERY)

TRANSITORY ISCHAEMIC ATTACK (TIA)
SYMPTOMS OF TIA INCLUDE:
- 1. APHASIA: DIFFICULTY FINDING WORDS. WHEN SPEECH CENTER IN DOMINANT
HEMISPHERE IS AFFECTED;
- 2. DYSARTHRIA: DIFFICULTY SPEAKING BECAUSE OF MOTOR DYSFUNCTION;
- 3. UNILATERAL SENSORY LOSS: NUMBNESS OR PARESTHESIA OF CONTRALATERAL
UPPER/LOWER EXTREMITIES OR FACE
- 4. UNILATERAL MOTOR LOSS: WEAKNESS, PARALYSIS, DYSARTHRIA, CLUMSINESS OF
UPPER/LOWER EXTREMITIES OF FACE, CONTRALATERAL TO THE AFFECTED CAROTID
ARTERY

PROLONGED REVERSIBLE ISCHAEMIC NEUROLOGIC DEFICIT
(PRIND)
PROLONGED REVERSIBLE ISCHAEMIC NEUROLOGIC DEFICIT (PRIND):
- NEUROLOGIC DEFICIT LASTS LONGER THAN 24 HOURS, BUT FULL NEUROLOGIC
FUNCTION RECOVERY WITHIN 48-72 HOURS
STROKE:
- PATIENTS WITH PERSISTENT NEUROLOGIC DEFICIT

AMAUROSIS FUGAX
SUDDEN ONSET AND LASTS FOR MINUTES
TRANSIENT UNILATERAL LOSS OF VISION, CAUSED BY EMBOLUS TO OPHTHALMIC ARTERY - 1ST
BRANCH OF ICA
PATIENTS DESCRIBE THE EVENT AS A SHADE ASCENDING OR DESCENDING OVER THE ENTIRE EYE,
HALF/QUADRANT OF ONE EYE
LOCATION OF AFFECTED VISUAL FIELD DEPENDS ON WHETHER EMBOLISATION IS TO SUPERIOR OR
INFERIOR RETINAL ARTERY
COMPLETE LOSS OF VISION IN ONE EYE: ENTIRE RETINAL ARTERY IS TRANSIENTLY AFFECTED
COMPLETE PERMANENT LOSS OF VISION AFTER AMAUROSIS FUGAX IN SOME PATIENTS

DIAGNOSIS
ONCE PATIENT IS DIAGNOSED WITH TIA, AMAUROSIS FUGAX OR STROKE, EXPEDIENT
WORKUP WITH CONFIRMATION OF CAROTID ARTERY DISEASE AND TREATMENT ARE
NEEDED BECAUSE THE RISK OF STROKE IS GREATEST WITHIN FIRST 3 MONTHS AFTER
INITIAL EVENT
- 1. CAROTID DUPLEX ULTRASONOGRAPHY;
- 2. CT ANGIOGRAPHY;
- 3. MR ANGIOGRAPHY;
- 4. CONTRAST ARTERIOGRAPHY

CAROTID DUPLEX ULTRASONOGRAPHY
MOST USEFUL TEST FOR DIAGNOSIS OF EXTRA-CRANIAL CAROTID ARTERY DISEASE
ACCURACY IN INDIRECT DETERMINATION OF SEVERITY OF CAROTID STENOSIS BY
MEASURING VELOCITY
STENOSIS INCREASES, LUMEN NARROWS - INCREASE IN BLOOD VELOCITY TO
MAINTAIN DISTAL FLOW
INCREASED VELOSITY WITH SEVERITY OF CAROTID ARTERY DISEASE IS CONFIRMED
BY MANY STUDIES

CT & MR ANGIOGRAPHY
USED TO DETERMINE THE DEGREE OF STENOSIS AT CAROTID
BIFURCATION
USEFUL TO STUDY POTENTIAL TANDEM LESIONS PRESENT OR
ABSENT IN PROXIMAL SUPRA-ARCH OR INTRACRANIAL
VESSELS
USEFUL TO STUDY THE CONFIGURATION OF THE AORTIC
ARCH
USEFUL FOR CONFIRMATION OF DUPLEX FINDINGS
USEFUL FOR PLANNING OF INTERVENTION WITH CAROTID
ENDARTERECTOMY (CEA) OR STENTING

CONTRAST ARTERIOGRAPHY
INVASIVE STUDY
IN PATIENTS FOR WHOM NON-INVASIVE
STUDY RESULTS ARE IN
DISAGREEMENT WITH CLINICAL
PRESENTATION
USUALLY PERFORMED IN PATIENTS
WHO UNDERGO SELECTIVE CORONARY
ANGIOGRAPHY
PERFORMED IN PATIENTS WITH
PREVIOUS HISTORY OF:
TIA,PRIND,AMAUROSIS FUGAX AND
STROKE

TREATMENT
- CAROTID ENDARTERECTOMY (CEA)

INDICATIONS
CAROTID ENDARTERECTOMY (CEA)
ACCORDING TO THE STROKE COUNCIL OF THE AMERICAN HEART ASSOCIATION FOR
SYMPTOMATIC PATIENTS:
- 1. ONE OR MORE TIAs IN LAST 6 MONTHS WITH CAROTID STENOSIS >/=70%;
- 2. MILD STROKE WITH CAROTID STENOSIS >/=70%;
- 3. TIAs IN PAST 6 MONTHS AND STENOSIS OF 50-60%;
- 4. PROGRESSIVE STROKE AND STENOSIS >/=70%;
- 5. MILD OR MODERATE STROKE IN PAST 6 MONTHS AND STENOSIS OF 50-60%;
- 6. CEA IPSILATERAL TO TIAs AND STENOSIS >/=70%, COMBINED WITH REQUIRED CABG

INDICATIONS
ACCORDING TO THE STROKE COUNCIL OF THE AMERICAN HEART ASSOCIATION FOR
ASYMPTOMATIC PATIENTS:
- STENOSIS >/=60%

SURGICAL TECHNIQUE
SUPINE WITH NECK EXTENDED AND HEAD TURNED TO CONTRALATERAL SIDE
LONGITUDINAL INCISION (BETTER EXPOSURE) PARALLEL AND ALONG ANTERIOR BORDER OF STERNOCLEIDOMASTOID MUSCLE /OBLIQUE INCISION (COSMETIC SCAR) -
ALONG SKIN LINES OF THE NECK
EXTENDING THE INCISION PROXIMALLY TO STERNAL NOTCH FOR BETTER EXPOSURE OF PROXIMAL CCA, DISTALLY TO MASTOID PROCESS - BETTER EXPOSURE OF DISTAL
ICA
PLATYSMA - DIVIDED; STERNOCLEIDOMASTOID MUSCLE - MOBILISED AWAY FROM CAROTID SHEATH AND RETRACTED POSTERIORLY
INTERNAL JUGULAR VEIN EXPOSED ALONG ANTERIOR BORDER UNTIL LARGE COMMON FASCIAL VEIN IS IDENTIFIED, THEN DIVIDED AND THE CAROTID BIFURCATION IS
LOCATED UNDERNEATH
VAGUS NERVE IS POSTEROLATERAL TO CCA IN CAROTID SHEATH
CAREFUL DISSECTION OF CCA TO AVOID INJURY TO VAGUS NERVE
METICULOUS DISSECTION OF CAROTID ARTERY TO AVOID EMBOLISATION
INITIAL DISSECTION LIMITED TO NORMAL ICA AND ECA DISTAL TO DISEASED SEGMENT AND CCA PROXIMAL TO DISEASED SEGMENT
DURING MOBILISATION OF ICA SUPERIORLY, HYPOGLOSSAL NERVE NEEDS IDENTIFICATION AND PROTECTION FROM INJURY
DISSECTION NEAR CAROTID BIFURCATION AND CAROTID BODY MAY RESULT IN REFLECTION BRADYCARDIA AND HYPOTENSION

SURGICAL TECHNIQUE
ONCE CAROTID ARTERIES ARE FULLY EXPOSED, VESSEL LOOPS ARE PLACED
AROUND ARTERIES
HEPARIN IS GIVEN FOR FULL ANTICOAGULATION
ICA CLAMPED FIRST, FOLLOWED BY CCA AND ECA
LONGITUDINAL ARTERIOTOMY OVER CCA, EXTENDED TROUGH THE PLAQUE INTO ICA
SHUNTING OPTION USING ELECTROENCEPHALOGRAPHIC OR BACK-PRESSURE
CRITERIA

SURGICAL TECHNIQUE
ENDARTERECTOMY STARTED IN CCA
ENDARTERECTOMY PLANE BETWEEN INNER AND OUTER MEDIAL LAYERS RESULTING IN REMOVAL OF INTIMA,
PLAQUE AND PORTION OF MEDIA
REMAINING ARTERIAL WALL THUS CONSISTS OF RESIDUAL MEDIA AND ADVENTITIA
PLAQUE IS PROXIMALLY DIVIDED IN CCA AND ENDARTERECTOMY -EXTENDED DISTALLY INTO CAROTID BULB
ENDARTERECTOMY OF ECA - SIMPLE EVERSION
ENDARTERECTOMY OF DISTAL ICA FEATHERED TO ITS TRANSITION TO NORMAL DISTAL INTIMA
AFTER COMPLETION OF ENDARTERECTOMY - RESIDUAL WALL COPIOUSLY IRRIGATED WITH HEPARINIZED SALINE
SOLUTION AND ANY REMAINING MEDIAL FIBERS AND DEBRIS ARE REMOVED TO PREVENT EMBOLISATION
ICA, ECA AND CCA ARE ALLOWED TO BACKBLEED

SURGICAL TECHNIQUE
THE ARTERIOTOMY IS CLOSED WITH SYNTHETIC PATCH
PATCH ANGIOPLASTY HAS BETTER RESULTS, COMPARED DO DIRECT SURURE, WITH REDUCED RISK OF RE-
STENOSIS, ESPECIALLY IN:
- 1. FEMALE PATIENTS;
- 2. PATIENTS WITH SMALL ICAs;
- 3. PATIENTS WHO CONTINUE TO SMOKE
AFTER ARTERIOTOMY PATCH CLOSURE IS FINISHED, FLOW IS FIRST ESTABLISHED TO ECA, WITH RELEASE OF
CLAMPS TO ECA AND CCA
AFTER SEVERAL HEARTBEATS TO FLUSH DEBRIS OUT OF ECA, FLOW IS THEN REESTABLISHED INTO ICA
HEPARIN REVERSAL IS GIVEN WITH PROTAMINE

POSTOPERATIVE CARE
GROSS NEUROLOGIC EXAMINATION OF THE PATIENT IS PERFORMED IN THE
OPERATING ROOM AT THE COMPLETION OF ENDARTERECTOMY
IF NO DEFICIT IS FOUND, THE PATIENT IS TRANSFERRED TO RECOVERY OR REGULAR
WARD ROOM
IN NEUROLOGIC DEFICIT IS FOUND, PATENCY OF ICA IS EVALUATED WITH NON-
INVASIVE CAROTID DUPLEX ULTRASOUND
IF INTIMAL FLAP OR OCCLUSION OF ICA IS DETECTED - IMMEDIATE REOPERATION

POSTOPERATIVE CARE
OF PARAMOUNT IMPORTANCE TO PREVENT STROKE AFTER ENDARTERECTOMY ARE:
- 1. BLOOD PRESSURE MONITORING;
- 2. BLOOD PRESSURE CONTROL.
SYSTOLIC BLOOD PRESSURE SHOULD BE KEPT:
- 1. BELOW 140 MMHG IN NORMOTENSIVE PATIENTS;
- 2. BELOW 160 MMHG IN CHRONICALLY HYPERTENSIVE PATIENTS
HYPERTENSION SHOULD BE TREATED IMMEDIATELY (SODIUM NITROPRUSSIDE CAN BE USED)
DIASTOLIC BLOOD PRESSURE SHOULD BE KEPT BELOW 100 MMGH
HYPOTENSION IS INITIALLY TREATED WITH FLUID, CORRECTING VOLUME DEFICIT, BUT IF REFRACTORY -
VASOCONSTICTORS

POSTOPERATIVE CARE
THE USE OF ANTIPLATELET THERAPY AND INTRAOPERATIVE HEPARIN ANTICOAGULATION CAN CAUSE
HAEMATOMA AFTER ENDARTERECTOMY
USUALLY, THERE IS DIFFUSE OOZE FROM THE WOUND RATHER THAN BLEEDING FROM SUTURE LINE
LARGE HAEMATOMA MAY CAUSE:
- 1. COMPRESSION ON ICA;
- 2. ADJACENT CRANIAL NERVES;
- 3. INFECTION;
- 4. AIRWAY COMPROMISE, IN WHICH THE INCISION NEEDS TO BE OPENED AT THE BEDSIDE FOR
DRAINAGE OF THE HAEMATOMA

POSTOPERATIVE CARE
HEADACHE AFTER CEA
3-5 DAYS POSTOPERATIVELY AND RESOLVES SPONTANEOUSLY
CAUSED BY REPERFUSION SYNDROME FROM DYSFUNCTION IN CEREBRAL
CIRCULATION AUTOREGULATION ONCE THE BLOOD FLOW IS RESTORED AFTER
ENDARTERECTOMY

STROKE (1-3%)
- EMBOLISATION FROM FRIABLE OR
ULCERATED PLAQUE DURING CAROTID
DISSECTION
- INADEQUATE CEREBRAL PERFUSION
DURING ENDARTERECTOMY
- THROMBOSIS FROM A FLAP OR
TECHNICAL ERROR
- REPERFUSION SYNDROME
INJURY OF CRANIAL NERVES (16-
39%)
COMPLICATIONS

TREATMENT
- CAROTID ANGIOPLASTY
&
STENT PROCEDURE

GENERAL INFORMATION
CAROTID ANGIOPLASTY WITH STENTING (CAS)
DESPITE CEA WAS ACCEPTED AS THE GOLD STANDARD FOR CAROTID ARTERY
DISEASE, A GROUP OF PATIENTS, BEEN IDENTIFIED AS HIGH-RISK FOR CEA, BENEFIT
FROM CAS
RAPID EVOLUTION DURING THE PAST DECADE OF CAS TECHNIQUE AND TECHNOLOGY
IS REALITY, AND AN ALTERNATIVE TO CEA THERAPY, WITH INTRODUCTION OF:
- 1. SELF-EXPANDING NITINOL STENTS;
- 2. SMALLER DELIVERY SYSTEMS;
- 3. EMBOLIC PROTECTION DEVICES (EPDs)

IMPORTANT CLINICAL TRIALS

INDICATIONS
SYMPTOMATIC HIGH-RISK PATIENTS FOR CEA WITH:
- 1. ANATOMIC CONDITIONS:
- RESTENOSIS AFTER PREVIOUS CEA CAUSED BY ASSOCIATION WITH HIGHER RISK OF CRANIAL NERVE
INJURY;
- “HOSTILE” NECK FROM PREVIOUS NECK RADIATION;
- RADICAL NECK DISSECTION;
- PERMANENT TRACHEOSTOMY;
- OTHER CAROTID LESIONS, INCLUDING TANDEM LESIONS WITHIN THE SAME CAROTID ARTERY AND
CONTRALATERAL ICA DISEASE

INDICATIONS
SYMPTOMATIC HIGH-RISK PATIENTS FOR CEA WITH:
- 1. PHYSIOLOGIC CONDITIONS:
- CLASS III/IV ANGINA OR CHF;
- SEVERE COPD;
- CARDIAC DISEASE NECESSITATING OPEN HEART SURGERY WITHIN 4 WEEKS

CONTRAINDICATIONS
COILS OR KINKING OF CCA OR ICA
EXCESSIVE CALCIFICATION OF CAROTID ARTERY DISEASE
DIFFICULT ACCESS BECAUSE OF:
- ILIAC DISEASE;
- TORTUOUS AND CALCIFIED ARCH;
- TANDEM CCA STENOSES.

TECHNIQUE
ORAL LOADING DOSE OF 600 MG. OF CLOPIDOGREL AND THEN MAINTAINED ON 75 MG. BY
MOUTH DAILY
RETROGRADE COMMON FEMORAL ARTERY ACCESS / BRACHIAL ARTERY ACCESS IN
SEVERE AORTO-ILIAC OCCLUSIVE DISEASE
DIAGNOSTIC ARCH AORTOGRAPHY WITH 4-VESSEL EXTRA-CRANIAL AND BILATERAL
CEREBRAL ARTERIOGRAPHY IS PERFORMED FOR EVALUATION OF CAROTID DISEASE,,
CEREBRAL CIRCULATION AND PROCEDURAL PLANNING
SUBCLAVIAN ARTERIES ARE CATHETERISED ALSO FOR EVALUATION OF VERTEBRAL
ARTERIES

TECHNIQUE
PLACEMENT OF EMBOLIC PROTECTION DEVICE - ACROSS THE STENOTIC LESION INTO THE DISTAL
ICA
CAROTID STENT PLACEMENT - THE STENT IS ADVANCED CAREFULLY ACROSS THE STENOTIC LESION
AND IS DEPLOYED FROM THE ICA INTO CCA, COVERING THE ORIGIN OF ECA. SELF-EXPANDING
NITINOL STENT IS TYPICALLY 8-10 MM. IN DIAMETER BY 30 MM. IN LENGHT
CAROTID ANGIOPLASTY - ANGIOPLASTY BALLOON IS ADVANCED OVER GUIDEWIRE ACCROSS THE
LOCATION OF NARROWEST AREA OF THE STENT. THE BALLOON IS INFLATED SLOWLY UNTIL
APPOSITION IS ACHIEVED AND THEN DEFLATED SLOWLY
COMPLETION ANGIOGRAM - OBTAINED TO CONFIRM ADEQUATE RESOLUTION OF CAROTID DISEASE
AND TO ENSURE FLOW THROUG ICA. EPD - REMOVED. CLOSURE DEVICE TO CLOSE THE
ARTERIOTOMY

Carotid artery disease

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