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Surgical management of carotid artery atherosclerotic disease
1Department of Surgery, Duke University Medical Center, Durham, NC 27710.
Insights
Carotid atherosclerosis surgery effectively prevents strokes in symptomatic patients. However, evidence for surgical benefit in asymptomatic patients with carotid atherosclerosis is still under investigation.
Area of Science:
- Geriatric Medicine
- Neurology
- Vascular Surgery
Background:
- Cerebrovascular disease is a leading cause of death and disability in the elderly.
- Carotid atherosclerosis, particularly at the carotid bifurcation, is a primary cause of embolic strokes.
- Optimal medical therapy and surgical interventions are crucial for managing carotid atherosclerosis.
Purpose of the Study:
- To review the current understanding of carotid atherosclerosis pathogenesis.
- To evaluate the efficacy of medical and surgical treatments for stroke prevention.
- To assess the role of carotid endarterectomy in both symptomatic and asymptomatic patients.
Main Methods:
- Review of current knowledge on carotid atherosclerosis.
- Analysis of large clinical trials, including the North American Symptomatic Carotid Endarterectomy Trial (NASCET).
- Discussion of diagnostic tools like ultrasonography and contrast angiography.
Main Results:
- Carotid endarterectomy significantly reduces stroke risk in symptomatic patients compared to optimal medical therapy, as shown by NASCET and other trials.
- Embolization from ulcerated plaques is the predominant stroke mechanism.
- Diagnostic imaging includes ultrasonography for screening and angiography for preoperative evaluation.
Conclusions:
- Carotid endarterectomy is a proven stroke prevention strategy for symptomatic patients.
- The benefit of surgery for asymptomatic patients with carotid atherosclerosis is not yet established.
- Ongoing trials are investigating the efficacy of intervention in asymptomatic individuals.
Abstract:
Cerebrovascular disease remains an important cause of disability and death in the geriatric population. This paper reviews the current state of knowledge with respect to the pathogenesis and medical and surgical treatment of carotid atherosclerosis. The majority of strokes are probably due to embolization from an ulcerated atherosclerotic plaque at the carotid bifurcation rather than from ischemia produced by global reduction in cerebral blood flow related to obstruction of the carotid arteries. Ultrasonography is an appropriate screening examination, but most vascular surgeons consider contrast angiography to be essential in the preoperative evaluation. Large clinical trials have evaluated the efficacy of stroke prevention by carotid endarterectomy in symptomatic patients. The North American Symptomatic Carotid Endarterectomy Trial clearly demonstrated a benefit of surgery in stroke prevention as compared with optimal medical therapy after only 18 months of follow-up. The European Carotid Surgery Trial and a VA Cooperative Study produced similar conclusions. Much less information is available concerning the patient with carotid atherosclerosis who has no cerebral symptoms. No convincing evidence that surgery is beneficial has yet been demonstrated, but a large multicenter clinical trial (Asymptomatic Carotid Atherosclerosis Study) remains in progress.