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 Carotid Artery Disease

By Matthew L. White MD and Joseph L. Mills, MD

Based on Curriculum outline originally prepared by: Alan M. Graham, MD, Wesley S. Moore, MD, William Baker, MD


Includes:

  • Atherosclerotic Carotid Artery Disease
  • Carotid Artery Fibromuscular Dysplasia
  • Carotid Artery Coils and Kinks
  • Carotid Artery Radiation Injury
  • Carotid Body Tumor
  • Overall Management of Stroke
  • Spontaneous Carotid Artery Dissection
  • Atherosclerotic Aortic Arch and Proximal Carotid Artery Disease

JUNIOR LEVEL

I. Anatomy and Pathophysiology

1. To describe the anatomy of the arch, great vessels, and intracranial arteries.
2. To describe the embryology of the above and relate the common anomalies to the embryology.
3. To understand the different etiologies of carotid artery disease.

a. Atherosclerosis
i. Define the systemic risk factors for atherosclerosis.
ii. Define the systemic effects of atherosclerosis and how these effects impact the diagnosis and treatment of the patient with carotid stenosis.
b. Kinking and tortuosity
c. Fibromuscular dysplasia
d. Compression
e. Traumatic occlusion
f. Acute dissection
g. Inflammatory arteriopathies

4. To describe the gross pathologic and histologic characteristics of each etiology above.
5. To discuss the mechanisms (occlusion and/or embolism) by which each underlying condition produces cerebral events

II. Diagnostic Evaluation

History and Physical Examination
1. To define hemispheric, non-hemispheric, and non-specific or atypical symptoms.
2. To differentiate among transient ischemic attack (TIA), stroke in evolution and completed stroke.
3. To describe the arterial and neurologic examinations and their importance in caring for patients with carotid artery disease.
4. To describe the relationship between carotid artery atherosclerosis and the clinical syndrome of vertebrobasilar insufficiency (i.e. patients with multiple vessel or combined carotid and vertebral disease and posterior symptoms).
5. To describe and defend the appropriate evaluation for patients with each of the above clinical presentations.

Carotid Duplex Examination

1. To be able to explain the basic fundamental principles of Doppler ultrasound.
2. To describe the normal Doppler waveforms in the internal, external, and common carotid arteries.
3. To discuss the sensitivity/specificity of duplex scanning to detect and grade carotid artery stenosis.
4. To discuss the risks and benefits of relying on duplex ultrasound and eliminating angiography.
5. To understand the basics of Vascular Laboratory Accreditation process

III. Treatment

Treatment of Neurologic Syndromes in Patients with Carotid Stenosis
1. To discuss the non-surgical and surgical treatment of acute ischemic syndromes including stroke.
2. To understand the basic data underlying the role and effectiveness of medical therapy (especially antiplatelet therapy and statin therapy) in the treatment of carotid bifurcation atherosclerosis.
3. To discuss the role of thrombolytic therapy in the treatment of acute stroke syndromes.
 a. To understand the indications and contraindications for lytic therapy in acute stroke.

Complications of Carotid Endarterectomy
1. To describe the etiology and management of:
a. Wound hematoma
b. Wound infection
c. Post-operative hyper and hypotension
d. Peripheral nerve palsies
e. Perioperative stroke
f. Non-carotid (predominantly cardiac) events

SENIOR LEVEL

I. Anatomy and Pathophysiology

1. To understand the collateral arterial communications of the extracranial and intracranial arteries.
2. To discuss the diagnosis of anomalies and collateral circulation utilizing diagnostic modalities including CT scan, MRI, SPECT, and transcranial Doppler.
3. To discuss the normal flow patterns at the carotid bifurcation, and how they influence the development of atherosclerotic disease (flow divider, shear stress).

II. Diagnostic Evaluation

Angiography and MRA
1. Angiography: to be able to discuss the technique, its limitations and complications.
2. MRA: to be able to discuss the technique, limitations and complications.
3. To discuss and compare the different methods of measuring carotid bifurcation stenosis (bulb-based versus distal ICA based).

Diagnostic Brain Scanning
1. For each of the following diagnostic modalities, explain the principles, indications, complications, and potential influence on the indications for carotid endarterectomy.
a. CT scan
b. MRI
c. SPECT
d. Transcranial Doppler

III. Treatment

Treatment of Neurologic Syndromes in Patients with Carotid Stenosis
1. To be able to construct a logical diagnostic and treatment algorithm for various stroke syndromes.
2. To be able to discuss the potential role of endovascular treatment.

Surgical Treatment
1. To discuss the intrathoracic and extrathoracic surgical options for treatment of atherosclerotic stenosis or occlusion of the great vessels.
2. To describe the standard approach to carotid endarterectomy including intraoperative shunting, patching, anesthetic techniques, tacking sutures and methods of completion evaluation.
3. To describe the surgical treatment of less common conditions such as fibromuscular dysplasia, kinking, radiation arteritis, tumors involving the carotid artery, other arteritides, and recurrent carotid stenosis.
4. To recognize the carotid sinus syndrome and discuss its treatment.
5. To discuss the role of EC-IC bypass.
6. To discuss the indications for and performance of proximal and distal vertebral artery reconstruction.

Complications of Carotid Endarterectomy
1. To describe the etiology and management of:
a. Transient ischemic attack and stroke
b. Asymptomatic thrombosis
c. Cerebral Reperfusion or Hyperperfusion syndrome

i. Perioperative hypertension and headache
ii. Intracranial hemorrhage
ii. Post-operative seizure

References

1. Rutherford R. Atlas of Vascular Surgery - Basic Techniques and Exposures. WB Sanders. 1993.
2. Rutherford R. Vascular Surgery. WB Sanders. Fifth Edition. 2010.
3. Osborne Anne G. Cerebral Angiography. Lippincott Williams and Wilkins. Philadelphia . 1999.
4. Moore, Wesley. Vascular Surgery: A Comprehensive Review. WB Sanders. Seventh Edition. 2006.
5. Hallett JW, Mills JL, Earnshaw JJ, Reekers JA, Rooke TW. Comprehensive Vascular and Endovascular Surgery. 2nd Edition. Mosby Elsevier. Philadelphia. 2009.
6. Masaryk TJ, Levin JS, Laus G. Magnetic Resonance Angiography. The Mosby Company. St. Louis . 1988:299 - 334
7. Lee SH, Rao K, Zimmerman RA. Cranial MRI and CT. Third Edition. McGraw - Hill. New York . 1992.
8. Fisher M, Sotak CH, Mimematsu K, et al. New Magnetic Resonance Techniques for Evaluating Cerebrovascular Diseases. Annals of Neurol . 32(2):115, 1992.
9. Edelmann RR, Mattle HP, Atkinson DJ, et al. MR Angiography. AJR. 154:937. 1990.
10. Wolfe PA, Kannel WB, McGee DL. Epidemiology of Strokes in North America . Stroke. 1:19, 1986.
11. Zarnis CK, Giddens DP, Bharadvaj BK, et al. Carotid Bifurcation Atherosclerosis: Quantitative Correlation of Plaque Location with Flow Velocity Profiles and Wall Shear Stress. J Circ Res. 53:502, 1983.
12. Berman SS, Bernhard VM, Erly WK, et al. Critical Carotid Artery Stenosis : Diagnosis, Timing of Surgery, and Outcome. J Vasc Surg . 20:499, 1994.
13. Rosenberg H. CRC Handbook of Carotid Artery Surgery, Facts and Figures. Second Edition. CRC Press, 1994.
14. Caplan LR. Vertebrobasilar Disease. Stroke. 12:111, 1981.
15. Hafer CD. Subclavian Steal Syndrome. Ann of Surg . 111:1074, 1976.
16. Johnston KW, Baker WH, Bormham SJ, et al. Quantitative Analysis of Continuous Wave Doppler Spectral Broadening for the Diagnosis of Carotid Disease, Results of a Multicenter Study. J Vasc Surg . 4:493, 1986.
17. Moore DJ, Miles RD, Ohgi S, et al. Reactive Accuracy of the Diagnostic Components of Noninvasive Carotid Arterial Tests: A Comparison of Pulsed Doppler Arteriography and Spectrum Analysis. J Vasc Surg . 3:502, 1986.
18. Moneta GL, Edwards JM, Chitwood RW, et al. Correlation of North American Symptomatic Carotid Endarterectomy Trial (NASCET) Angiographic Definition of 70% to 99% Internal Carotid Stenosis with Dopley Scanning. J Vasc Surg . 17:152, 1993.
19. Moneta GL, Edwards JM, Papanicolaou G, et al. Screening for Asymptomatic Internal Carotid Stenosis : Dopley Criteria for Discriminating 60% to 99% Stenosis . J Vasc Surg . 21:989, 1995.
20. Weibel J, Field WS. Tortuosity , Coiling, and Kinking of the Internal Carotid Artery: Etiology and Radiographic Anatomy. Neurology. 15:7, 1965.
21. The Casanova Study Grows: Carotid Surgery vs. Medical Therapy in Asymptomatic Carotid Stenosis . Stroke. 22:1229, 1991.
22. Hobson RW II, Weiss DG, Fields WS, et al. Efficacy of Carotid Endarterectomy for Aysymptomatic Carotid Stenosis . N Engl J Med. 328:221, 1993.
23. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Benificial Effect of Carotid Endartcrectomy in Symptomatic Patients with High - Grade Stenosis . N Engl J Med. 325:445, 1991.
24. European Carotid Surgery Trialists : Collaborative Group. European Carotid Surgery Trial: Interim Results for Symptomatic Patients with Severe or with Mild Carotid Stenosis . Lancet. 337:1235, 1991.
25. Hobson RW II, Weiss DG, Field WS, et al. Efficacy of Carotid Endarterectomy for Aysymptomatic Carotid Stenosis : The Veterans Affairs Cooperative Study Group. N Eng J Med. 328:221, 1993.
26. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy For Asymptomatic Carotid Artery Stenosis . JAMA. 273:142, 1995.
27. Smith DC , Smith LL, Hasso AN. Fibromuscular Dysplasia of the Internal Carotid Artery Treated by Creative Transluminal Ballon Angioplasty. Radiology. 155:645, 1985.
28. Thal ER: Injury to the Neck. In Moore EE, Mattox KL, Feliciano D ( eds ): Trauma, 2nd Ed. Norwalk, Ct. Appleton & Lange. 1988. 305 - 317
29. Vittl MJ, Thompson BW, Read RC, et al. Carotid - Subclavian Bypass: A Twenty - Two Year Experience. J Vasc Surg . 20:44, 1994.
30. Law M, Colburn MD, Moore WS, et al. Carotid - Subclavian Bypass for Brachiocephalic Occulusive Disease. Choice of Conduit and Long - Term Follow - Up. Stroke. 26:1565, 1995.
31. Jordan WD, Schroeder PT, Fisher WS, McDowell HA. A Comparison of Angioplasty with Stenting versus Endarterectomy for the Treatment of Carotid Artery Stenosis . Ann Vasc Surg . 11:2, 1997.
32. Diethrich EB, Ndiaye M, Reid DB. Stenting in the Carotid Artery: Initial Experience in 110 Patients. J Endovasc Surg . 3:42, 1996.
33. Stewart MT, Moritz MW, Smith RB, et al. The Natural History of Carotid Fibromuscular Dysplasia . J Vasc Surg . 3:305, 1986.
34. Hacke W, Kaste M, Fieschi C, et al. For the ECASS Study Group. Intravenous Thrombolysis with Recombinant Tissue Plasminogen Activator for Acute Hemispheric Stroke: The European Cooperative Acute Stroke Study (ECASS). JAMA. 294:1017, 1995.
35. The Multicenter Acute Stroke Trial - Europe Study Group. Thrombolytic Therapy with Streptokinase In Acute Ischemic Stroke. N Engl J Med. 335:145, 1996.
36. Wylie's Atlas of Vascular Surgery. Extracranial Cerebrovascular Disease. J.B. Lippencott Company, 1992.

Posted September 2010