Carotid artery disease

Question 1

European Carotid Stenting Trial Measurement

Answer 1

The more logical one

Measure internal carotid across just after division = total diameter
At same point, measure intraluminal diameter

Divide difference over total diameter

Gives larger stenosis measurement

Question 2

NASCET Measurement

Answer 2

Illogical one with smaller measurement

Measure distal healthy ICA diameter = total diameter

Measure intraluminal diameter just after division

Divide the difference over total diameter

Question 3

Imaging guidelines for extracranial carotid artery stenosis

Answer 3

DUS (as first-line imaging), CTA and/ oMRA are recommended for evaluating the extent and severity of extracranial carotid stenoses IB

When CAS is being considered, it is recommended that any DUS study be followed by either MRA or CTA to evaluate the aortic arch as well as the extra- and intracranial circulation IB

When CEA is considered, it is recommended that the DUS stenosis estimation be corroborated by either MRA or CTA (or by a repeat DUS study performed in an
expert vascular laboratory) IB

Question 4

Management of asymptomatic carotid artery stenosis

Answer 4

=no symptoms in last 6 months

In ‘average surgical risk’ patients with an asymptomatic 60–99% stenosis, CEA should be considered in the presence of clinical and/or more imaging characteristicsc that may be associated with an increased risk of late ipsilateral stroke, provided documented perioperative stroke/death rates are <3% and the patient’s life expectancy is > 5 years IIaB

In asymptomatic patients who have been deemed ‘high risk for CEA’d and who have an asymptomatic 60–99% stenosis in the presence of clinical and/or imaging characteristicsc that may be associated with an increased risk of late ipsilateral stroke, CAS should be considered, provided documented perioperative stroke/death rates are <3% and the patient’s life expectancy is > 5 years. IIaB

In ‘average surgical risk’ patients with an asymptomatic 60–99% stenosis in the presence of clinical and/or imaging characteristicsd that may be associated with an increased risk of late ipsilateral stroke, CAS may be an alternative to CEA provided documented perioperative stroke/death rates are <3% and the patient’s life expectancy is > 5 years IIbB

Question 5

Features associated with increased risk of stroke in patients with asymptomatic carotid stenosis treated medically

Answer 5

Clinical: contralateral TIA/stroke

Imaging: ipsilateral silent infarct

USS:

• stenosis progression >20%
• spontaneous emboli on transcranial doppler
• impaired cerebrovascular reserve
• large plaques
• echolucent plaques
• increase juxta-luminal black hypoechogenic area

MRA

• intraplaque haemorrhage
• lipid rich necrotic core

Question 6

Management of symptomatic carotid artery stenosis

Answer 6

CEA is recommended in symptomatic patients with 70-99% carotid stenoses, provided the documented procedural death/ stroke rate is < 6%. IA

CEA should be considered in symptomatic patients with 50–69% carotid stenoses, provided the documented procedural death/ stroke rate is < 6%. IIaA

In recently symptomatic patients with a 50–99% stenosis who present with adverse anatomical features or medical comorbidities that are considered to make them ‘high risk for CEA’, CAS should be considered, provided the documented procedural death/stroke rate is < 6%. IIaB

When revascularization is indicated in ‘average surgical risk’ patients with symptomatic carotid disease, CAS may be considered as an alternative to surgery, provided the documented procedural death/stroke rate is < 6%.IIbB

When decided, it is recommended to perform revascularization of symptomatic 50–99% carotid stenoses as soon as possible, preferably within 14 days of symptom onset IA

Revascularization is not recommended in
patients with a < 50% carotid stenosis. IIIA

Question 7

Cut-off values for symtpomatic and asymptomatic

Answer 7

<50% = always BMT

<60% and asymptomatic = always BMT

Asymptomatic 60-99%, IF HIGH-RISK OF STROKE –> CEA and BMT
If not high-risk = BMT

Symptomatic 50-69% = consider CEA and BMT

Symptomatic 69-99% = CEA and BMT

Question 8

Symptomatic 69-99%

Answer 8

= CEA and BMT

Question 9

Symptomatic <50%

Answer 9

<50% = ALWAYS BMT

Question 10

Asymptomatic <60%

Answer 10

= always BMT

Question 11

Symptomatic 50-69%

Answer 11

Consider CEA and BMT

Question 12

Asymptomatic 60-99%

Answer 12

If high-risk –> CEA and BMT

If no high-risk features –> BMT alone

Question 13

Management of vertebral artery stenosis

Answer 13

In asymptomatic patients, manage entirely conservatively irrespective of level of stenosis

In patients with >50% stenosis, who have recurrent symptoms despite BMT consider revascularisation