Elsevier

Cardiology Clinics

Volume 33, Issue 1, February 2015, Pages 1-35
Cardiology Clinics

Management of Extracranial Carotid Artery Disease

https://doi.org/10.1016/j.ccl.2014.09.001Get rights and content

Section snippets

Key points

  • Asymptomatic patients without risk factors should not be screened for carotid atherosclerotic disease.

  • Carotid ultrasonography should be the initial screening tool for symptomatic patients.

  • Medical management, including antiplatelet therapy, is indicated in all symptomatic patients with carotid atherosclerotic disease, independent of degree of stenosis.

  • In general, carotid revascularization is indicated in symptomatic patients with nonocclusive moderate to severe stenosis (>50%) and asymptomatic

Carotid Ultrasonography

When performed by well-trained, experienced technologists, carotid US is accurate and relatively inexpensive.33, 34, 35, 36, 37, 38 Carotid US is also noninvasive, and does not require a venipuncture or exposure to contrast material or radiation. As such, carotid US is recommended for the initial evaluation of symptomatic and asymptomatic patients with suspicion for carotid atherosclerotic disease.39

Carotid US should be performed in asymptomatic patients with 2 or more of the following risk

Medical management

Pharmacologic therapy for patients with carotid atherosclerotic disease consists mainly of antiplatelet therapy and medical management of the risk factors for atherosclerotic disease.

Interventional management

Atherosclerotic disease of the extracranial carotid arteries carries significant morbidity and mortality risk despite maximal medical therapy. NASCET demonstrated a stroke rate of 19% to 33% after 18 months of medical therapy without intervention among symptomatic patients, depending on the degree of stenosis.19 Interventional management, consisting mainly of carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS), has been shown to decrease the stroke rate among these patients.8

Evaluation for recurrence and recurrence management

Noninvasive imaging at the 1-month interval, followed by the 6-month interval, and then annually after revascularization, is recommended for both CAS and CEA patients. Regular imaging allows for adequate assessment of ipsilateral carotid patency and to exclude development of contralateral lesions. Once stability has been established, surveillance at longer intervals may be appropriate. Surveillance may not be indicated when the patient is no longer a candidate for intervention.

The mechanism

Summary

There are several imaging modalities available for the screening and diagnosis of carotid atherosclerotic disease, and treatment consists mainly of medical and interventional management.

Carotid US has a relatively low cost, minimal side effects and discomfort, and is widely available. It should be used as the initial screening tool for both symptomatic and asymptomatic patients with suspected carotid disease. Other more advanced noninvasive imaging, such as MRA and CTA, can be used when US

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    Research reported in this publication was supported by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health (award number K23NS079477-01A1). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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