Holding Pressure: Carotid Endarterectomy

Audible Bleeding

Authors:

Sebouh Bazikian - MS4 at Keck School of Medicine of University of Southern California

Gowri Gowda - PGY1 at the University of California Davis Integrated Vascular Surgery Program

Steven Maximus- Vascular surgery attending at the University of California Davis, Director of the Aortic Center

Resources:

• Rutherford’s 10th Edition Chapters: 88, 89, and 91

• The North American Symptomatic Carotid Endarterectomy

• Asymptomatic Carotid Atherosclerosis Study

• Audible Bleeding’s eBook chapter on cerebrovascular disease

• Houston Methodist CEA Dissection Video:

Part 1: https://www.youtube.com/watch?v=wZ8PzhwmSXQ

Part 2: https://www.youtube.com/watch?v=E_wWpRKBy4w

Outline:

1. Etiology of Carotid Artery Stenosis

• Risk factors: advanced age, tobacco use, hypertension, diabetes.

• Atherosclerosis as the primary cause.

2. Development of Atherosclerotic Disease and Plaque Formation

   • LDL accumulation in arterial walls initiating plaque formation.

   • Inflammatory response, macrophage transformation, smooth muscle cell proliferation.

   • Role of turbulent blood flow at carotid bifurcation in plaque development.

3. Clinical Features of Carotid Artery Stenosis

   • Asymptomatic nature in many patients.

   • Symptomatic presentation: Transient ischemic attacks, amaurosis fugax, contralateral weakness/sensory deficit.

   • Carotid bruit as a physical finding, limitations in diagnosis.

4. Importance of Evaluating CAS

   • Assessing stenosis severity and stroke risk.

   • Revascularization benefits dependent on stenosis severity.

5. Classification of Stenosis Levels

   • Clinically significant stenosis: ≥ 50% narrowing.

   • Moderate stenosis: 50%–69% narrowing.

   • Severe stenosis: 70%–99% narrowing.

6. Stroke Risk Associated with Carotid Stenosis

   • Annual stroke rate: ~1% for 50-69% stenosis, 2-3% for 70-99% stenosis.

7. Diagnosis and Screening

   • No population-level screening recommendation.

   • Screening for high-risk individuals as per SVS guidelines.

   • Carotid Duplex Ultrasound as primary diagnostic tool.

   • Additional tools: CT angiography, Magnetic Resonance Angiography.

   • Handling of 100 cm/sec, Internal/Common Carotid peak systolic velocity Ratio > 4.

10. Revascularization Criteria

    • Symptomatic Patients: 50-69% or 70-99% stenosis, life expectancy at least three or two years, respectively.

    • Asymptomatic Patients: 70% stenosis, considering life expectancy.

11. Surgical Indications and Contraindications

    • Indications: symptomatic patients, life expectancy considerations.

    • Contraindications: Stenosis