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Chapter 20 - Carotid and Vertebral Artery Revascularization

from Part V - Prevention

Published online by Cambridge University Press:  15 December 2020

By
Mandy D. Müller ,
Leo H. Bonati  and
Martin M. Brown
Edited by
Jeffrey L. Saver  and
Graeme J. Hankey
Jeffrey L. Saver
Affiliation:
David Geffen School of Medicine, University of Ca
Graeme J. Hankey
Affiliation:
University of Western Australia, Perth
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Summary

With the exception of near-occlusion, CEA is of overall benefit for selected patients with recent symptomatic carotid stenosis =50% (NASCET method), provided surgical stroke/death risk is low. The benefit is greater with greater stenosis, men, the elderly (aged =75y), most recent ischaemic event within 2w, irregular plaque surface, and impaired cerebral perfusion reserve. Patients with recent symptomatic carotid territory ischaemic events should be screened by Doppler ultrasonography, MRA, or CTA, confirming substantial stenosis with a second non-invasive investigation. Catheter angiography may be required to confirm uncertain results. The surgical peri-operative stroke and death rate (7% in RCTs) is higher in women, hypertension, peripheral arterial disease, and occlusion of the contralateral ICA or ipsilateral ECA. The experience of the surgeon and hospital are crucial, and audited peri-operative complication rates should be publically available. Carotid stenting is less invasive than CEA and causes fewer local complications (cranial neuropathy and neck haematoma), but carries a higher procedural risk of stroke. Stenting should be considered in younger patients, or those at increased risk from CEA. While stenting is of high risk for intracranial vertebral artery stenosis, risk is low for extracranial stenosis and should be considered for recurrent symptoms despite optimal medical therapy.

Keywords

Carotid stenosiscarotid endarterectomycarotid angioplastystentingvertebral stenosisischaemic stroketransient ischaemic attackdiagnosispreventiontreatmentperi-operative complications
Type
Chapter
Information
Stroke Prevention and Treatment
An Evidence-based Approach
 , pp. 412 - 449
Publisher: Cambridge University Press
Print publication year: 2020

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