Current Treatments for Carotid Artery Disease
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Published:
Feb 18, 2011
Keywords:
Carotid artery disease Carotid atherosclerosis Carotid Sclerosis carotid stenting Staging endarterectomy
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Abstract
Carotid artery disease is one of the main causes of stroke, apart from other cardiac causes or disease of the brain itself. About 80% of all strokes are ischemic and approximately 25-50% of these are caused by an unstable carotid artery plaque.1 The risk factors for carotid stenosis are similar to those for athero- sclerosis and include hypertension, diabetes, cigarette smoking and dyslipidemia. Prevention of stroke caused by carotid bifurcation stenosis can be achieved by accurate identification and evaluation of patients at risk. Pathophysiology of carotid atherosclerosis is similar to that in other vascular beds. However, atherosclerosis in the carotid artery is usually unifocal, and 90% of lesions are located within 2 cm. of the internal carotid artery (ICA) origin. Extracranial internal carotid artery stenosis accounts for 15 to 20% of ischemic strokes, depending on the population studied. The degree of carotid stenosis is associated with the degree of stroke risk. Carotid ath- erosclerosis can produce retinal and cerebral symptoms by way of 1 of 2 major mechanisms. progressive carotid stenosis leading to insitu occlusion and hypoperfusion (less common), or intracranial arterial occlusion resulting from embolization (more common). Embolism from unstable plaque is the major mechanism of stroke in carotid atherosclerosis.2,3 Stroke is more likely to be due to embolism rather than hypoperfusion even in patients with >70% carotid stenosis, and the risk of stroke may be lower in patients with >90% stenosis, due to post-stenotic narrowing in the distal ICA, which reduces flow and risk of embolism. Patients present- ing with carotid distribution cerebral ischemia should be thoroughly evaluated for treatable causes, including sources of emboli from the carotid arteries, heart, and aortic arch. Patients with or without carotid stenosis may also develop symptomatic cerebral hypoperfusion from systemic causes.
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Thupvong K, Ruengsakulrach P. Current Treatments for Carotid Artery Disease. BKK Med J [Internet]. 2011 Feb. 18 [cited 2024 Apr. 27];1(1):49. Available from: https://he02.tci-thaijo.org/index.php/bkkmedj/article/view/217661
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References
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2. Shi ZS, Feng L, He X, Ishii A, Goldstine J, Vinters HV, Vinuela F. Vulnerable plaque in a Swine model of carotid atherosclerosis. AJNRAm J Neuroradiol 2009;30(3):469-472
3. Kolodgie FD, Gold HK, Burke AP, Fowler DR, Kruth HS, Weber DK, Farb A, Guerrero LJ, Hayase M, Kutys R, Narula J, Finn AV, Virmani R. Intraplaque hemorrhage and progression of coronary atheroma. N Engl J Med 2003;349(24):2316-2325
4. Muluk SC, Muluk VS, Sugimoto H, Rhee RY, Trachtenberg J, Steed DL, Jarrett F, Webster MW, Makaroun MS. Progression of asymptomatic arotid stenosis: a natural history study in 1004 patients. J Vasc Surg 1999;29(2):206-214
5. Chaturvedi S, Bruno A, Feasby T, Holloway R, Benavente O, Cohen SN, Cote R, Hess D, Saver J, Spence JD, Stern B, Wilterdink J. Carotid endarterectomy--an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005;65(6):794-801
6. Clinical alert: benefit of carotid endarterectomy for patients with high-grade stenosis of the internal carotid artery. National Institute of Neurological Disordersand Stroke Stroke and Trauma Division. North American Symptomatic Carotid Endarterec-tomy Trial (NASCET) investigators. Stroke 1991;22(6):816-817
7. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998;351(9113):1379-1387
8. Albers GW, Caplan LR, Easton JD, Fayad PB, Mohr JP, Saver JL, Sherman DG. Transient ischemic attack- proposal for a new definition. N Engl J Med 2002;347 (21):1713-1716
9. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.North American SymptomaticCarotidEndarterectomyTrialCollaborators. N Engl J Med 1991;325(7):445-453
10. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists’ Collaborative Group. Lancet 1991;337(8752): 1235-1243
11. Wardlaw JM, Lewis S. Carotid stenosis measurement on colour Doppler ultrasound: agreement of ECST, NASCET and CCA methods applied to ultrasound with intra-arterial angiographic stenosis measurement. Eur J Radiol 2005;56(2):205-211
12. Oates CP, Naylor AR, Hartshorne T, Charles SM, Fail T, Humphries K, Aslam M, Khodabakhsh P. Joint recommendations for reporting carotid ultrasound investigations in the United Kingdom. Eur J Vasc Endovasc Surg 2009;37(3):251-261
13. Lovett JK, Gallagher PJ, Hands LJ, Walton J, Rothwell PM. Histological correlates of carotid plaque surface morphology on lumen contrast imaging. Circulation 2004;110(15):2190-2197
14. O’Donnell TF, Jr., Erdoes L, Mackey WC, McCullough J, Shepard A, Heggerick P, Isner J, Callow AD. Corre lation of Bmode ultrasound imaging and arteriography with pathologic findings at carotid endarterectomy. Arch Surg 1985;120 (4):443-449
15. Wintermark M, Jawadi SS, Rapp JH, Tihan T, Tong E, Glidden DV, Abedin S, Schaeffer S, Acevedo-Bolton G, Boudignon B, Orwoll B, Pan X, Saloner D. High-resolution CT imaging of carotid artery atherosclerotic plaques. AJNR Am J Neuroradiol 2008;29(5):875-882
16. Das M, Braunschweig T, Muhlenbruch G, Mahn- ken AH, Krings T, Langer S, Koeppel T, Jacobs M, Gunther RW, Mommertz G. Carotid plaque analysis: comparison of dual-source computed tomography (CT) findings and histopathological correlation. Eur J Vasc Endovasc Surg. 2009;38(1):14-19
17. Hermus L, van Dam GM, Zeebregts CJ. Advanced carotid plaque imaging. Eur J Vasc Endovasc Surg 39(2):125-133
18. Bots ML, Mulder PG, Hofman A, van Es GA, Grobbee DE. Reproducibility of caroti vessel wall thickness measurements. The Rotterdam Study. J Clin Epidemiol 1994;47(8):921-930
19. Burke GL, Evans GW, Riley WA, Sharrett AR, Howard G, Barnes RW, Rosamond W, Crow RS, Rautaharju PM, Heiss G. Arterial wall thickness is associated with prevalent cardiovascular disease in middle-aged adults. The Atherosclerosis Risk in Communities (ARIC) Study. Stroke 1995;26(3):386-391
20. Bots ML, Hoes AW, Koudstaal PJ, Hofman A, Grobbee DE. Common carotid intima-media thickness and risk of stroke and myocardial infarction: the Rotterdam Study. Circulation 1997;96(5):1432-1437
21. Blauw GJ, Lagaay AM, Smelt AH, Westendorp RG. Stroke, statins, and cholesterol. A meta-analysis of randomized, placebo-controlled, double-blind trials with HMG-CoA reductase inhibitors. Stroke 997;28(5): 946-950
22. Van Wissen S, Trip MD, Smilde TJ, de Graaf J, Stalenhoef AF, Kastelein JJ. Differential hs-CRP reduction in patients with familial hypercholes- terolemia treated with aggressive or conventional statin therapy. Atherosclerosis 2002;165(2):361-366
23. Hodis HN, Mack WJ, LaBree L, Selzer RH, Liu C, Alaupovic P, Kwong-Fu H, Azen SP. Reduction in carotid arterial wall thickness using lovastatin and dietary therapy: a randomized controlled clinical trial. Ann Intern Med 1996;124(6):548-556
24. Smilde TJ, van Wissen S, Wollersheim H, Trip MD, Kastelein JJ, Stalenhoef AF. Effect of aggressive versus conventional lipid lowering on atherosclerosis progression in familial hypercho lesterolaemia (ASAP): a prospective, randomised, double-blind trial. Lancet 2001;357(9256):577-581
25. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008;25(5):457-507
26. Amarenco P, Bogousslavsky J, Callahan A, 3rd, Goldstein LB, Hennerici M, Rudolph AE, Sillesen H, Simunovic L, Szarek M, Welch KM, Zivin JA. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med 2006;355(6):549-559
27. Collins R, Armitage J, Parish S, Sleight P, Peto R. Effects of cholesterol-lowering with simvastatin on stroke and other major vascular events in 20536 people with cerebrovascular disease or other high-risk conditions. Lancet 2004;363(9411):757-767
28. Amarenco P, Goldstein LB, Szarek M, Sillesen H, Rudolph AE, Callahan A, 3rd, Hennerici M, Simunovic L, Zivin JA, Welch KM. Effects of intense low-density lipoprotein cholesterol reduction in patients with stroke or transient ischemic attack: the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial. Stroke 2007;38 (12):3198-3204
29. Amarenco P, Labreuche J. Lipid management in the prevention of stroke: review and updated meta-analysis of statins for stroke prevention. Lancet Neurol 2009;8(5): 453-463
30. Hedblad B, Wikstrand J, Janzon L, Wedel H, Berglund G. Low-dosemetoprolol CR/XLand fluvastatin slow progression of carotid intima-media thickness: Main results from the Beta-Blocker Cholesterol- Lowering Asymptomatic Plaque Study (BCAPS). Circulation 2001;103(13):1721-1726
31. Weber R, Weimar C, Diener HC. Medical prevention of stroke and stroke recurrence in patients with TIA and minor stroke. Expert Opin Pharmacother 2009;10(12): 1883-1894
32. Theiss W, Hermanek P, Mathias K, Bruckmann H, Dembski J, Hoffmann FJ, Kerner R, Leisch F, Mudra H, Schulte KL, Sievert H. Predictors of death and stroke after carotid angioplasty and stenting: a subgroup analysis of the Pro-CAS data. Stroke 2008;39(8):2325-2330
33. Gray WA, Yadav JS, Verta P, Scicli A, Fairman R, Wholey M, Hopkins LN, Atkinson R, Raabe R, Barnwell S, Green R.The CAPTURE registry: predictors of outcomes in carotid artery stenting with embolic protection for high surgical risk patients in the early post-approval setting. Catheter Cardiovasc Interv 2007;70(7):1025-1033
34. Stingele R, Berger J, Alfke K, Eckstein HH, Fraedrich G, Allenberg J, Hartmann M, Ringleb PA, Fiehler J, Bruckmann H, Hennerici M, Jansen O, Klein G, Kunze A, Marx P, Niederkorn K, Schmiedt W, Solymosi L, Zeumer H, Hacke W. Clinical and angiographic risk factors for stroke and death within 30 days after carotid endarterectomy and stentprotected angioplasty: a subanalysis of the SPACE study. Lancet Neurol 2008;7(3):216-222
35. Hassan AE, Zacharatos H, Vazquez G, Rodriguez GJ, Suri MF, Tummala RP, Taylor RA, Qureshi AI. Low Risk of Intracranial and Systemic Hemorrhages in Patients on Dual Antiplatelet Treatment Beyond 1 Month Following Neuroedvascular Angioplasty and/ or Stent Placement. J Neuroimaging 2010.
36. Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 2001;357(9270):1729-1737
37. Bonati LH, Ederle J, McCabe DJ, Dobson J, Feather- stone RL, Gaines PA, Beard JD, Venables GS, Markus HS, Clifton A, Sandercock P, Brown MM. Long-term risk of carotid restenosis in patients randomly assigned to endovascular treatment or endarterectomy in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVA-TAS) long-term follow-up of a randomised trial. Lancet Neurol 2009;8(10): 908-917
38. Murad MH, Flynn DN, Elamin MB, Guyatt GH, Hobson RW, 2nd, Erwin PJ, Montori VM. Endarterectomy vs stenting for carotid arterytenosis: a systematic review and meta-analy-sis. J Vasc Surg 2008;48(2):487-493
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