Clinical presentation: see stroke
- cervical bruits useful but non-specific; only 30-50% will have
significant stenosis; only 20-50% with significant stenosis have a
- minority will present with TIA; 50% significant carotid disease
pts present up-front with a stroke
- risk of stroke in asymptomatic pt with a significant stenosis is
10-15%; after a TIA, risk rises to 25% in a year; after stroke, 50%
5-yr risk, 50% of which are fatal.
Carotid duplex uss
- anatomic information and assessment of flow velocities
- occasionally MRA and CTA for improved anatomical detail.
- minimal role for angio.
Indications for endarterectomy
Clear benefit vs medical management for stensoses 70-99% (NASCET
trial and ECST trial)
- 50-69% benefit less given morbidity rates; probably justified at
- symptomatic disease >50% for internal carotid stenosis (>60%
- asymptomatic disease >60% internal carotid stenosis (again,
higher threshold if comorbidities)
Mortality now <1% (usually cardiac) and stroke periop down to
Nerve injury important complication (hypoglossal>recurrent
Recurrent stenosis is usually from intima hyperplasia early; late
may get recurrence of atheroma
- particularly seen in women, smokers, high cholesterol, diabetics,
- reoperation is technically challenging with higher risk; may need
Endovascular role advancing; angioplasty balloons and self-expanding
stents have a growing role
Still highly challenging and a high-volume specialist procedure
Past studies were not so promising, with higher risk, but in expert
hands can outperfrom those poor outcomes significantly
- has harmed respectability of CES as a procedure.
But ongoing refinement will grow role.
Can cause neurologic deficit / stroke, local pressure (nerve
impingment) or rarely, frank rupture.
Treat if symptomatic, >2cm or nerve compression.