Carotid Treatment (vascular unit 1 )

What are the medical treatments that control risk factors?

Control risk factors

Exercise regularly

Lose weight

Quit smoking

Change dietary habits

Control diabetes

what are the medications that control carotid disease and what do each do?

Medications

 Blood thinners, Lowers platelet aggregation, Aspirin / plavix / persantin

 Statins, Lowers cholesterol

 ACE inhibitors, Control blood pressure

what are the surgical treatment

Stent

Endarterectomy

Bypass

For carotid Artery stenting (CAS), how effective is this treatment? what are the clinical trials and what are the limitations?

Has gained in prominence

 Treatment just as effective as endarterectomy

 Clinical trials

 CREST

 CAVATAS

 SAPPHIRE

 Limitations

 Contrast allergies

Angioplasty

what type of technique is this? what is used to image the vessel, how is it placed?

Angioplasty

Angioplasty

Seldinger technique

X-ray dye is used to image vessel

Catheter manipulation

Open the vessel – balloon

angioplasty

Deploy the stent

Stent is placed in where and what does it have a potential for (risk?)

 Stent is placed in the narrowed

region

 Potential for emboli; basket “placed”

above narrowed region to catch any

emboli

what are the abnormal findings for stent (3?)

Residual / Recurrent stenosis

Myointimal hyperplasia

Stent malposition

what is Residual / Recurrent stenosis

Atheromatous plaque formation

what is Myointimal hyperplasia

Growth of what? develop at where? replaces what layer and what can it lead too? lower risk for what?

Growth of cells

 Develop at the stent site over a

period of time

 Replaces the removed intimal layer

 Can lead to stenosis

 Lower risk for stroke / occlusion

what is Stent malposition

Not in correct position

 Stent has peeled away from the wall

Abnormal findings

Duplex US

both carotid systems evaluated, interval testing is 1-2 years

every 6 months is indicated if what?

Velocity numbers

– >75% DR, what is the PSV, EDV, ICA:CCA Ratio

every 6 months is indicated if residual / recurrent ipsilateral or contralteral lesions (>50% DR)

Velocity numbers

– >75% DR

 PSV = >300cm/s 

EDV = 125-140cm/s

 ICA:CCA ratio = >4:1

what is Endarterectomy explain the procedure and what layers are removed

Surgical procedure

 Plaque is removed from the artery

 Carotid is opened length-wise

 Temporary shunt is placed to bypass

disease segment

 Plaque is removed

 Intima and media layers

 Carotid is sewn back together using

a synthetic patch

Endarterectomy sonographic appearance

what layers do you not see?

sutures can appear how?

wall thickening can occur-2 types

doppler appearance how

Sonographic appearance

 Absent intima / media stripe

 Sutures can appear as echogenic

reflector

 Wall thickening can occur

 Intimal hyperplasia

 Re-stenosis can occur

 Doppler appearance

 Color – disturbed/flow

separation

 Spectral – low velocity, disturbed

waveform

what are the abnormal findings for Endarterectomy… explain what its due too and what are the potential to cause

Abnormal findings

 Residual / recurrent stenosis

 Due to atheromatous plaque

 Intimal hyperplasia

 Intimal flap

 Distal end of endarterectomy site

 Cause flow disturbances

 Potential to cause

 Dissection

 Thrombosis

 Restenosis

Endarterectomy abnormal findings more

Myointimal hyperplasia

 Causes focal / diffuse

narrowing

 Overgrowth of tissue layer

that replaces the removed

intima

 Occur within the first 3

years of surgery

 Lower risk for stroke /

occlusion

Endarterectomy

Abnormal Findings

 Duplex ultrasound of bilateral carotid

systems

 Duplex surveillance is performed every 1-2

years

 6-month interval surveillance with

>50% DR

Velocity numbers for >75% DR

what are the PSV, EDV, ICA:CCA ratio

PSV >300cm/s

 EDV > 125-140cm/s

 ICA:CCA ratio >4

Bypass procedure explain what it is

Procedure in which blood is rerouted

around a severely diseased section of an

artery

 Long segment arterial disease

 Aneurysm

 Infections

 Cancer

 Radiation arteritis

 Recurrent stenosis post

endarterectomy

what are the Bypass methods

Graft material

Carotid: performed as a last resort

Much higher incidence of morbidity

Bypass Graft material autogenous vs gortex

Autogenous: using a vessel from the

patient

 Gortex: preferred material

for bypass which is performed as a last resort and why would that be ?

Carotid: performed as a last resort

 Endarterectomy was unsuccessful

 Patient not a viable candidate for

endarterectomy

for bypass Much higher incidence of morbidity

Second surgical procedure

 Patients are more critical

Bypass contraindications and what are the types

Underlying and unstable disease

conditions

 Poor circulation distally

 Poor inflow disease

Types

 CCA to CCA ipsilateral

 CCA to ICA ipsilateral

 CCA to CCA contralateral

Bypass complications are what

Cranial nerve injury

 Stroke

Horner Syndrome

Hematoma

Graft thrombosis

Graft infection

what are the Post procedure follow up for bypass

Duplex sonography

 CTA

 MRA

 Conventional angiography