Dr. Pankaj Patel vascular surgeon performs stenosis of internal carotid artery

		Peripheral Arterial Disease
		Acute Limb Ischaemia
		Buerger's Disease
		Raynaud's Disease


	Carotid Artery Disease

Atherosclerosis is common at the bifurcation of the common carotid artery

Stenosis of the internal carotid artery is a potentially treatable cause of:

A patient with an asymptomatic 50% carotid stenosis has 1-2% per year risk of a stroke

The risk of stroke increases with the degree of stenosis

Once a stenosis has become symptomatic the risk of a stroke is further increased

Once an ischaemic stroke has occurred the risk of further stroke is ~10% in the first year and ~5% in subsequent years

Assessment of stenosis

	Carotid bruits are an unreliable guide to severity of stenosis
	May be absent in patients with severe stenosis

Duplex ultrasound

	Doppler recordings allow assessment of flow at stenosis
	Also allows imaging of arterial anatomy

Carotid angiography

	Intra-arterial angiography is the traditional method of assessing degree of stenosis
	4% risk of inducing further neurological event
	1% risk of permanent stroke

Magnetic resonance angiography

An increasingly used non-invasive technique

Some surgeons will operate on the basis of non-invasive assessments

Medical Management

Stop smoking

Pharmacological treatment of hypertension and diabetes

Prophylactic aspirin

		Asprin prevents around 40 'vascular events' per 1000 patients treated for 3 years
		It should be started at 175-150 mg daily once ischaemic stroke confirmed by CT
		It should also be given to those with asymptomatic stenoses
		The combination of aspirin and dipyridamole is no more effective than aspirin alone.

Surgery for asymptomatic stenosis

Asymptomatic Carotid Atherosclerosis Study

1662 patients with >60% reduction in luminal diameter

Randomised to either

		Endarterectomy + medical treatment (aspirin 300 mg)
		Medical treatment alone

Risk of ipsilateral stroke over 5 year period was reduced (5% vs. 11%) in surgery group

2.3% in surgery group had stroke within 30 days of surgery

0.4% in medical group had stroke in same time period

Overall, benefit for those with asymptomatic stenosis but only the presence of a low perioperative complication rate.

Surgery for symptomatic stenosis

Two large trials have been published

North American Symptomatic Carotid Endarterectomy Trial (NASCET)

	Compared endarterectomy plus medical treatment in those patients with
	Non-disabling stroke in 4-6 months prior to surgery
	Severe (70-99%) ipsilateral stenosis
	The risk of stroke or death over 2 years was reduced (9% vs. 26%) in surgery group
	5.8% randomised to surgery had stroke within 30 days
	Benefit also seen in those with >50% stenosis but not to same degree

European Carotid Surgery Trial (ECST)

	ECST risk of stroke or death over 3 years was reduced (12% vs. 22%) in surgery group
	7.5% randomised to surgery had stroke or died within 30 days of operation
	In those with mild (0-30%) and moderate (30-60%) symptomatic stenoses there was benefit from surgery
	Overall, In those with symptomatic stenoses
	Best results are seen in those with more severe stenoses
	Benefit only seen in institutions with low perioperative stroke and death rate
	Surgery indicated in those with severe stenosis (>70%) that have recently become symptomatic
	Operation should be performed by experienced surgeon
	Centres should audit their results and have a perioperative stroke rate of <7%
	Angina and hypertension should be well controlled pre-operatively
	If patient selection is poor or complication rate high then there will be no benefit from surgery.

Carotid angioplasty

	Angioplasty (± stent placement) is being used to dilate stenoses
	No published randomised trials
	In uncontrolled studies severe stenoses (>70%) have been dilated to <50%
	Re-stenosis often occurs and a significant risk of stroke during the procedure