A 77-year-old female presented to the emergency department with difficulty breathing and was found to have pulmonary edema and left ventricular hypertrophy. During her hospital stay, a carotid bruit was discovered and Doppler ultrasound revealed 80-99% stenosis of the right carotid artery. She was scheduled for a right carotid endarterectomy to address the high-grade stenosis, a procedure she tolerated well without complications. Medical management has improved for asymptomatic carotid stenosis but intervention may still benefit high-risk patients.

1. Carotid Stenosis
John R. Martinelli, OD, FAAO
MD Candidate, SGUSOM 14’
Newark Beth Israel Medical Center
Department of Surgery
July 23, 2013

2. HPI
• 77yo F presents to ED via EMS on 7/10/13
• CC: Extreme Difficulty Breathing & Sweating
• Intubation by EMS
• Unknown Systemic Hx

3. ED Exam
• Vitals: 98.5, 77, 16, 237/94, 100% (Intub)
• Sedation via Versed (Midazolam)
• CXR: Bilateral Pulmonary Edema
• ECG: LVH

4. Labs
• WBC: 12.7 (4.5 – 11.0)
• Na: 146 (135 – 145)
• K: 3.2 (3.5 – 5.1)
• PT: 10 (11 – 15)

5. Assessment/Plan
• LVH with CHF and Pulmonary Edema/Respiratory
Failure - Secondary to probable uncontrolled
chronic HTN.
• Continue Intubation/Vent
Diuresis with Lasix
Max Anti-HTN Tx
Troponins
Stress ECG

6. IP @ 4 days
• BP 150/40
• Stress ECG (Dobutamine)
(-) Ischemia
• Troponins (-)
• BUN: 28 (7 – 18)
Cr: 1.36 (0.6 – 1.2)
• …Overall Improvement…Discharge?

7. Carotid Bruit
• Right Carotid Bruit discovered IP Day 4
• Stat Doppler US -> 80 – 99% Stenosis R
• Additional Meds: Asa + Statin
• No Associated Neuro Symptoms
• Px Scheduled 7/22/13 SDS R CEA

8. Imaging

9. Carotid Doppler

10. Carotid Doppler

11. Carotid Doppler

12. Carotid Doppler

13. Carotid Stenosis Risks
• Atherosclerotic Factors
-Hypertension
-Diabetes
-Hyperlipidemia/Hypercholesterolemia
-Obesity
-Smoking
-EtOH
-Carotid Bifurcation
• CAD
• LVH!

14. CAD <-> CAS
J Am Coll Cardiol. 2011;57(7):779-783.
doi:10.1016/j.jacc.2010.09.047
The severity of CAS and the extent of coronary
artery disease (CAD) were significantly correlated (r
= 0.255, p < 0.001). Independent predictors of
severe CAS defined by PSV were the presence of
left-main or 3-vessel CAD, increasing age, a history
of stroke, smoking status, and diabetes mellitus.

15. LVH -> CAS?
Heart and Vessels
May 2013, Volume 28, Issue 3, pp 277-283
This study shows that the presence of LVH and
higher EAT thickness together improves prediction
of CPs in hypertensive patients with 0–1 risk factor
and that those with ≥2 RFs show high prevalence of
CPs independently of LVH and/or EAT.

16. CAS Signs/Symptoms
• Asymptomatic -> -> -> TIA -> -> -> CVA
• Neurologic Deficits
-Dependent on Path of Emboli
-Contalateral Hemiparesis/Paralysis
-Contralateral Sensory Deficits
-Aphasia (Afluent vs. Fluent)
-Visual Field Defect(s)
-Amaurosis Fugax

17. Hollenhorst Plaque

18. Hollenhorst Plaque

19. Non-Arteritic Anterior Ischemic Optic Neuropathy

20. Non-Arteritic Anterior Ischemic Optic Neuropathy

21. Asymmetric and/or Normal Tension Glaucoma

22. Carotid Endarterectomy
• Indications
- Symptomatic
One or more transient ischemic attacks (TIAs) in the
preceding 6 months and carotid artery stenosis exceeding
50%
Ipsilateral TIA and carotid artery stenosis exceeding 70%, combined with required coronary
artery bypass grafting (CABG)
Progressive stroke and carotid artery stenosis exceeding 70%
Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid
Endarterectomy Trial Collaborators. N Engl J Med. Aug 15 1991;325(7):445-53.
- Asymptomatic
Good Risk Pxs with > 60% Stenosis
Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA. May 10
1995;273(18):1421-8.

23. Medical Management
May 7 issue of the Annals of Internal Medicine
Tufts Medical Center, Boston, Massachusetts.
"The medical management of patients with asymptomatic
carotid stenosis has improved significantly over the past 20
years, with stroke rates having come down markedly,"
coauthor David E. Thaler, MD, PhD, commented to Medscape
Medical News. "While there may be a role for invasive
approaches such as stenting and endarterectomy in high-risk
patients, it is not clear if these interventions are superior to
medical therapy in the modern era; more work is needed to
better identify high-risk patients and to test the interventional
approaches in this group."

24. Endarterectomy Exposure

25. Endarterectomy Overview
• Local or General Anesthesia
• Careful Dissection (n,a,v)
• CCA, ICA, ECA Clamped
• ICA Incision
• Shunt (Brenner)
• Removal of Thrombus
• ICA Closure & Removal of Shunt

26. CEA 7/22/13
• Patient tolerated procedure well without
complication.
• PACU monitor Q15min x 4hrs
• IP hourly monitor
• ASA QD
• BP

27. Other Considerations
• CEA vs Stent?
• Bilateral Surgery?
• Contralateral Stenosis?
• Emergent CEA?