VASCULAR SOLUTIONS - Vascular and Endovascular Surgeons Treating Peripheral Vascular Disease in Cleveland, Ohio

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Carotid plaque obtained during a carotid endarectomy.

Note the hemoragic soft material in the center of the plaque

Plaque may partially or totally block the blood's flow through an artery. Two things that can possibly happen where plaque occurs:

1. Bleeding (hemorrhage) into the plaque

2. Formation of a blood clot (thrombus) on the plaque's surface.

If a patient has a significant blockage or plaque in the carotid artery, if clot or particles breakaway the patient may develop a tia or stroke. Such a patient is described as having a symptomatic carotid artery. If a patient does not have symptoms, then it is entirely symptom free or more commonly referred to as an asymptomatic carotid narrowing. The risks of these two different circumstances and options will discussed later in this discussion.

Based on a history and a physical exam, carotid disease may be suspected. On physical exam, a sound may be made by the narrowing and often can be heard with a stethoscope (bruit). Noninvasively, an ultrasound/duplex uses sound waves to measure the velocity of blood in a respective blood vessel. Based on a well described set of parameters, a narrowing may be determined very accurately. Additionally, MRI or CT Scans may be used to characterize a narrowing. Arteriography of the aortic arch and carotid is often considered the ultimate method of determining the degree of stenosis.

The thorny issue is once the degree of relative stenosis has been determined is to correlate it with the history and physical exam. We must now consider the issue of symptomatic and asymptomatic hemodynamically significant disease.

Diagnosis:

North American Symptomatic Carotid Endarterectomy Trial (NASCET) (N Engl J Med. 1991;325:445–453 ) This trial confirmed the effectiveness of carotid endarterectomy in preventing stroke in 659 symptomatic patients who had TIAs or minor strokes with high-grade (70 to 99 percent), diameter-reducing carotid artery stenosis. Randomized prospective clinical trials have clearly showed that carotid endarterectomy is a highly beneficial treatment modality compared with the best medical treatment for patients with hemispheric and retinal TIAs or nondisabling strokes and ipsilateral high-grade stenosis of the internal carotid artery. Carotid endarterectomy is three times as effective as medical therapy alone in reducing incidence of stroke in patients with symptomatic stenosis of 70% to 99%.With a low surgical risk, carotid endarterectomy provides modest benefit in symptomatic patients with carotid artery stenosis of 50 to 69 percent. Platelet antiaggregants and risk factor modification are recommended in symptomatic

Symptomatic:

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