Carotid Artery Disease

Stroke is the 3rd leading cause of death in the United States, with more than 500,000 stroke victims annually. One-third of these patients expire within 30 days of their stroke, while another third are permanently disabled. The costs associated with stroke exceed $30 billion per year. Atherosclerotic carotid disease is responsible for approximately 50-60 percent of strokes. These facts motivate stroke risk-reduction strategies of screening and intervention.

Carotid ultrasound remains the fundamental screening technique for symptomatic (TIA or stroke) or asymptomatic persons with risk factors (smoking, hypertension, diabetes, hypercholesterolemia, coronary artery disease, peripheral vascular disease). Many patients are prepared for intervention on the basis of ultrasound results alone. If the anatomic diagnosis is in doubt, need for intervention can rapidly be resolved with either CT or MR angiography. Femoral artery puncture for conventional catheter angiography and its associated risks is rarely needed today.

For the last 40 years, carotid endarterectomy (CEA) - open surgical treatment of the blockage in the carotid artery - has been the "gold standard" for treatment of significant carotid stenosis, or blockage. CEA provides direct carotid arterial control, prevention of embolic particles from reaching the cerebral circulation, and allows for complete removal of the atheromatous plaque under direct vision. CEA has yielded excellent and durable results with a significant stroke risk reduction in all populations studied when performed for conventionally accepted indications:

  1. symptomatic patients with stenosis >70% and
  2. asymptomatic patients with stenosis >80%)(1, 2).

In the hands of experienced vascular surgeons, such as those at Redwood Regional Vascular Associates, the stroke rate associated with endarterectomy is expected to be 2% or less.

American Heart Association
Society for Vascular Surgery - Carotid Endarterectomy Information

Carotid artery stenting has recently emerged as a treatment alternative to endarterectomy. Proponents of stenting argue that it is less invasive and has lower risks for nerve damage, hematoma, and infection compared to endarterectomy. Thromboembolic events during stenting continue to limit widespread use of this technique. Several recent stenting trials have shown the stroke and death rate to be higher for stenting relative to endarterectomy, especially in patients over 80 years old. (3, 4) In addition, costs for stenting are higher than those for endarterectomy.

Carotid artery stenting is currently approved by Medicare only for non-investigational use in symptomatic patients considered to be at high risk for traditional, open endarterectomy because of cardiac, pulmonary or anatomic constraints. Members of the Redwood Regional Vascular Associates are qualified and experienced in carotid artery stenting and are able to perform this procedure if clinically indicated at Santa Rosa Memorial Hospital.

Society for Vascular Surgery - Carotid Stenting Information

References:

  1. North American Symptomatic Carotid Endarterectomy Trial collaborators: Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 325: 445-453, 1991
  2. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study: Endarterectomy for asymptomatic carotid artery stenosis. JAMA 273: 1421-1428, 1995
  3. CREST Investigators: Carotid artery stenting is associated with increased complications in octogenarians: 30-day stroke and death rates in the CREST lead-in phase. J Vasc Surg. 40(6):1106-11, 2004.
  4. EVA-3S Investigators: Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355:1660-1671