Chapter 53. Principles of Endovascular Therapy

Question 1

Question 53-1: 
A 65-year-old mao presents with a left carotid bruit and is found on carotid ultrasonography to have 95% left ICA stenosis. Angiography confinns the severity of the focal stenosis. Which is currently the best approach to treatment? 
A.  Medical management 
B.  Carotid endarterectomy 
C  Carotid angioplasty 
D.  Carotid angioplasty with stent

Answer 1

Answer 53-1: B.
Carotid endarterectomy is still the most
appropriate treatment for a patient with
asymptomatic carotid stenosis who is
otherwise a good operative candidate. Carotid
angioplasty is performed, especially in
patients who are poor surgical candidates.
Recent evidence suggests that endovascular
therapy may be safer than conventional
carotid endarterectomy in symptomatic
patients. (p998-999)

Question 2

Question 53-2:
Which of the following would make a patient with carotid atherosclerotic disease at high risk and thereby encourage consideration of endovascular therapy.
A. Previolls radiation therapy to the neck
B. Contralateral total occlusion of the carotid artery
C.Tandem lesion with extracranial and intracranial disease in the same vascular distribution
D. Restenosis after previous endarterectomy
E. All of these

Answer 2

Answer 53-2: E.
All of these are potential causes of consideration of carotid endovascular surgery rather than endarterectomy. A major factor not
listed is high lesion, inaccessible to
conventional surgery. (p1001)

Question 3

Question 53-3:
Which statement correctly describes the status of extracranial-intracranial bypass for carotid occlusive disease?
A. EC-IC bypass surgery is indicated for total internal carotid occlusion
B. EC-IC bypass surgery is indicated for TIAs in the setting of tandem carotid stenoses
C. EC-IC bypass surgery does not reduce the risk of stroke compared tomedical therapy

Answer 3

Answer 53-3: C.
EC-IC bypass surgery has all but been
discarded since it has not been shown to be
effective in reducing the risk of stroke in comparison to medical therapy. (p 1002)

Question 4

Question 53-4:
What is the role of cerebral protection devices in carotid stenting?
A. Cerebral protection devices eliminate the possibility of stroke associated with stenting procedures
B. Cerebral protection devices reduce the incidence of procedure-related stroke by about 50%
C. Cerebral protection devices have not been shown to have any benefit

Answer 4

Answer 53-4: B. Cerebral protection devices are small baskets
which are placed downstream from the site of
angioplasty and stenting. They reduce the
incidence of stroke associated with the
procedure from almost 7% to 3.25%. (p998)

Question 5

Question 53-5:
Endovascular treatment for unruptured
intracramal aneurysms is sometimes performed. Which of the following statements are true for this new approach?
A. The risk of endovascular therapy is less than that of conventional surgery
B. The incidence of incomplete aneurysm obliteration is higher with endovascular therapy
C. Treated aneurysms can recanalize
D. All are true

Answer 5

Answer 53-5: D.
All of these are true. The rate of incomplete
aneurysm obliteration and the potential for
recanalization are disadvantages of
endovascular treatment. On the other hand, the
procedural risk is less than that of
conventional surgery. (p 1012)

Question 6

Question 53-6:
All of the following factors would Suggest endovascular therapy for aneurysm EXCEPT which?
A . Multiple medical problems which place the patient at elevated surgical risk
B. Failed clipping attempt, with even higher risk of repeated surgical approach
C. Patient refusal of conventional surgery
D. Single aneurysm amenable to endovascular therapy rather than multiple aneurysms which would require surgery

Answer 6

Answer 53-6: D.
Endovascular surgery would be entertained.
especially if there were multiple aneursms
which might otherwise require multiple
craniotomies. Another indication for
endovascular therapy is a location of geometry
ofthe aneurysm which would make
conventional surgery high risk or impossible.
(p1013)

Question 7

Question 53-7:
What is the role of embolization in head and neck tumors?
A. Preoperative reduction in blood flow
B. Postoperative infarction of residual tumor
C. Most effective in gliomas
D. All of these are true

Answer 7

Answer 53-7: A.
Preoperative reduction in blood flow to
tumors of the head and neck is the most
common application of tumor embolization.
This is most used for meningiomas and
glomus tumors. (p994)

Question 8

Question 53-8: 
Following carotid angioplasty and stent, what type of medical therapy is appropriate? 
A.  ASA alone 
B.  ASA plus clopidogrel 
C.  Warfarin 
D.  None

Answer 8

Answer 53-8: B.
Combination antiplatelet therapy with aspirin
plus clopidogrel is the most commonly used
regimen after carotid angioplasty and stenting.
This regimen comes from the cardiology
literature with stenting of coronary arteries. In
addition, studies have shown that combination
antiplatelets are more effective than single
agents in prevention of stroke. Warfarin
appears to be inferior to combination
antiplatelet agents for prevention ofrestenosb
following stent. (p999)

Question 9

Question 53-9:
What is the current status of intra-arterial thrombolytic therapy for acute stroke?
A. IA thrombolytic therapy has replaced IV t•PA for patients with acute stroke
B. Recent data are promising but this avenue is still under study
C. Recent data indicate no potential role for this modality

Answer 9

Answer 53-9: B.
Intra-arterial thrombolytic agents are a
promising modality for treatment of acute
stroke. Intra-arterial therapy will probably be
used in conjunction with emergent use of
intravenous thrombolytics, but the:e is still
much to learn about the indications,
techniques. and limitations of these
procedures. (p 1006-1008)

Question 10

Question 53-10:
What is the current status of intravenous thrombolytic therapy for acute infarction?
A. Intravenous t-PA has been shown to reduce neurologic disability
B. IV t-PA i associated with a greater risk of intracranial hemorrhage than control patients
C. If given, IV t-PA must be administered within three hours of onset of symptoms
D. All are true

Answer 10

Answer 53-10: D.
All of these are true. There are individuals
who are not convinced about the effectiveness
of IV t·PA. However, when used according to
established guidelines, patients are 30% more
likely to have little or no neurologic disability.
UnfortuDately, top A is associated v.;th an
increased risk of hemorrhage, but this can be
limited by adherence to inclusion and
exclusion guidelines. Time more than three
hours and hypertension are believed to
increase the risk of hemorrhage. (p 1006)