Carotid Endarterectomy and Carotid Stenting

CHAPTER 24 Carotid Endarterectomy and Carotid Stenting







BACKGROUND


Stroke is the third leading cause of death in the United States. More than 700,000 strokes occur annually. Additionally, nonfatal strokes result in substantial morbidity and health care expenditures; the American Heart Association estimated this cost to be $18 billion annually in 1993. Strokes are broadly categorized as hemorrhagic (20%) or ischemic (80%); up to 30% of ischemic strokes attributable to carotid disease.


C. Miller Fisher, a neurologist, first recognized the relationship between atherosclerotic disease of the carotid bifurcation and symptoms of ipsilateral monocular blindness and contralateral hemiplegia in 1951. Atherosclerotic plaque formation in the carotid bulb may lead to embolization of friable plaque or thrombus and subsequent neurologic deficits. Rarely, a flow-limiting stenosis of the carotid artery results in symptomatic cerebral hypoperfusion. Because it is a manifestation of atherosclerosis, carotid disease is associated with hypertension, diabetes, hyperlipidemia, and tobacco use. Patients with carotid disease may present with transient ischemic attacks (TIAs), defined as neurologic deficits lasting less than 24 hours. These embolic events are often associated with focal motor or language and speech deficits. Alternatively, patients present with amaurosis fugax (monocular blindness secondary to embolization of the ophthalmic artery, a branch of the internal carotid artery). Physical examination of patients with carotid disease may reveal a carotid bruit, reflecting turbulent flow through a stenotic lesion. Importantly, the presence of a bruit does not reflect the severity of stenosis, and patients may have severe carotid stenoses in the absence of a bruit. Duplex examination is the most frequently used screening modality to assess carotid disease and has largely supplanted physical examination.


Carotid endarterectomy (CEA), the subject of this chapter, is a well-established mode of primary stroke prevention in patients with carotid disease. The use of carotid angioplasty and stenting has emerged as an alternative to CEA in selected patients and is discussed in brief.



INDICATIONS FOR SURGERY








May 26, 2018 | Posted by in GENERAL SURGERY | Comments Off on Carotid Endarterectomy and Carotid Stenting

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