Carotid Notes

Clinical presentation: see stroke
Notes
- cervical bruits useful but non-specific; only 30-50% will have significant stenosis; only 20-50% with significant stenosis have a bruit.
- 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.

Imaging
Carotid duplex uss
- anatomic information and assessment of flow velocities
- occasionally MRA and CTA for improved anatomical detail.
- minimal role for angio.

Treatment
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 >60%
Bottom line:
- symptomatic disease >50% for internal carotid stenosis (>60% if comborbidites)
- asymptomatic disease >60% internal carotid stenosis (again, higher threshold if comorbidities)

see technique

Outcomes
Mortality now <1% (usually cardiac) and stroke periop down to 1-5%
Nerve injury important complication (hypoglossal>recurrent laryngeal>superior laryngeal>marginal mandibular>glossopharyngeal>spinal accessory)
Recurrent stenosis is usually from intima hyperplasia early; late may get recurrence of atheroma
- particularly seen in women, smokers, high cholesterol, diabetics, hypertensives
- reoperation is technically challenging with higher risk; may need replacement graft.

Endovascular therapies
Endovascular role advancing; angioplasty balloons and self-expanding stents have a growing role
Still highly challenging and a high-volume specialist procedure only.
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.

Carotid aneurysms?
Can cause neurologic deficit / stroke, local pressure (nerve impingment) or rarely, frank rupture.
Treat if symptomatic, >2cm or nerve compression.