Mod X: Anesthesia for CAROTID ARTERY DISEASE

Question 1

Anesthesia for CAROTID ARTERY DISEASE

OBJECTIVES

Answer 1

1. State the indications for carotid endarterectomy
2. State several frequent co-existing diseases in patients with carotid artery disease
3. Describe the anesthetic management of patients undergoing carotid endarterectomy
4. Discus intraoperative maneuvers that are utilized to preserve cerebral blood flow

Question 2

_{BACKGROUND CVA AND CAROTID ARTERY DISEASE}

What’sthe 4th leading cause of death in the U.S. and the leading cause of long-term disability?

Answer 2

Stroke

Stroke is the 4th leading cause of death in the U.S.

Leading cause of long-term disability

Also a Major contributor to increased health care costs

(estimated at $65.8 billion in 2008)

With aging population, an increasing amount of patients will present to the OR with cerebral vascular disease

Question 3

_{BACKGROUND CVA AND CAROTID ARTERY DISEASE}

There is a strong correlation between strokes and

Answer 3

Carotid artery disease

Question 4

_{BACKGROUND CVA AND CAROTID ARTERY DISEASE}

CVA may occur from

Answer 4

Embolization of a thrombus or

Plaque debris that cause a reduction in flow

Question 5

_{BACKGROUND CVA AND CAROTID ARTERY DISEASE}

Regardless of the cause of injury the degree of cerebral injury depends on:

Answer 5

Plaque morphology

Characteristics of the embolus

Duration of hypoperfusion

Integrity of the circle of Willis

Degree cerebral collateral circulation present

Question 6

_{CEREBRAL BLOOD FLOW (CBF)}

Brain is 2% of body weight, but receives what % of CO?

Answer 6

12-15% of cardiac output

Question 7

_{CEREBRAL BLOOD FLOW (CBF)}

Total CBF averages

Answer 7

50 ml/100g/min

(750 ml/min)

Question 8

_{CEREBRAL BLOOD FLOW (CBF)}

Which CBF levels constitute adequate blood flow?

Answer 8

CBF levels >50 ml/100g/min

Question 9

_{CEREBRAL BLOOD FLOW (CBF)}

Which CBF levels are inadequate? are these a/w permanent injury?

Answer 9

20-50 ml/100g/min CBF is inadequate, but

No permanent injury occurs if blood flow restored

Question 10

_{CEREBRAL BLOOD FLOW (CBF)}

Which CBF levels may lead to permanent injury?

Answer 10

CBF <20 ml/100g/min => injury will occur

Question 11

_{CBF AUTOREGULATION}

The phenomenom whereby cerebral blood flow adapts appropriately to changes in mean arterial pressure (MAP) is known as:

Answer 11

Autoregulation

Cerebral blood vessels will constrict when MAP increases and dilate when MAP decreases

Question 12

_{CBF AUTOREGULATION}

What’s the purpose of Autoregulation?

Answer 12

Serves to maintain a constant CBF despite swings in MAP

Question 13

_{CBF AUTOREGULATION}

CBF is autoregulated in humans between which MAP values?

Answer 13

60-160 mmHg

Question 14

_{CBF AUTOREGULATION}

What is CBF regulated by for MAP values >60 or >160?

Answer 14

CBP will be passively regulated by MAP

Question 15

_{AUTOREGULATION CURVE}

With chronic hypertension the Autoregulation curve shifts to:

Answer 15

The Right

Autoregulation curve shifts to the right with chronic hypertension

This causes the lower and higher ends of the autoregulation range to be higher than in a normotensive pt

This could potentially protect the brain from transient high MAPs

But it occurs at the expense of raising lower limits, which causes an increase risk of ischemia at lower MAPs that would be otherwise tolerated well in a normotensive pt

This is why Hypertensive patients may develop cerebral ischemia at MAPs easily tolerated by normotensive patients

Question 16

_{AUTOREGULATION CURVE}

With chronic hypotension the Autoregulation curve shifts to:

Answer 16

The Left

Question 17

_{CBF AND CHEMICAL CONTROL}

What type of relationship exist between CBF and PaCO2 between arterial CO2 25-75 mmHg?

Answer 17

Linear relationship

Linear relationship between CBF and PaCO2 between arterial CO2 25-75 mmHg

Question 18

_{CBF AND CHEMICAL CONTROL}

How does CO2 causes cerebral vasodilation?

Answer 18

B/c CO2 diffuses freely into the CNS, causing increased concentration of H+ and dilation of the cerebral vessels

This is how Hypoventilation => cerebral vasodilation and inc CBF

Question 19

_{CBF AND CHEMICAL CONTROL}

Oxygen tension has an inverse relation with CBF?

Answer 19

Hyperventilation => cerebral vasoconstriction and dec CBF

However, Low arterial oxygen tension increases CBF

When PaO2 fall bellow 50mmHg, there is a rapid inc in CBF

Question 20

_{CAROTID ARTERY ENDARTERECTOMY}

Most common peripheral vascular surgical procedure

Answer 20

CAROTID ARTERY ENDARTERECTOMY

Estimated 130K procedures performed annually

Question 21

_{CAROTID ARTERY ENDARTERECTOMY ​}

Stenosis most commonly at

Answer 21

the bifurcation of the common carotid artery

Question 22

_{CAROTID ARTERY ENDARTERECTOMY ​}

Endarterectomy used to reduce symptoms and prevent stroke for over 50 years - why?

Answer 22

Low risk procedure with excellent long-term durability

Many trials have been completed in an effort to recommend the best treatment for pts w/ carotid artery dz, which over the years has actually cause an increase in the number of carotid endarterectomy performed

While carotid surgery has demonstrated postive effects, the terminative benefit must be determined for each pt in order to keep peri-operative strokes and death rates low

Perioperative stroke and death rates must stay low in order to maintain the beneficial effects of surgery over medical therapy

Question 23

_{AHA GUIDELINES FOR CAROTID ENDARTERECTOMY}

Based on AHA practice recommendations regarding carotid endarterectomies, which Factors are r/t increased risk of stroke?

Answer 23

Age, HTN, ischemic heart disease, diabetes, hyperlipidemia, diabetes, cigarette smoking, & high HCT.

HTN and smoking = two most powerful and treatable risk factors for stroke

Question 24

_{AHA GUIDELINES FOR CAROTID ENDARTERECTOMY}

Based on AHA practice Recommendations for symptomatic and asymptomatic patients regarding carotid endarterectomies, CAE recommended for symptomatic patients with Carotid Artery Dz of what % stenosis?

Answer 24

>70% stenois

Must also consider operative stroke and death rate along with life expectancy

Question 25

_{AHA GUIDELINES FOR CAROTID ENDARTERECTOMY} Based on AHA practice Recommendations for symptomatic and asymptomatic patients regarding carotid endarterectomies, CAE recommended for asymptomatic patients with Carotid Artery Dz of what % stenosis?

Answer 25

\>60 stenosis Must also consider operative stroke and death rate along with life expectancy

Question 26

_{PREOPERATIVE ANESTHETIC EVALUATION} Pre-op considerations for carotid artery dz include

Answer 26

Carotid artery dz does not occur in isolation Evaluate for Systemic arterial dz Perform a detailed system assessment Evaluate and Optimize clinical status regarding coexisting diseases Defining pre-existing neurological deficits

Question 27

_{PREOPERATIVE ANESTHETIC EVALUATION} Pre-op Manegment Poorly controlled HTN

Answer 27

Gradual decrease of BP over several weeks prior to surgery May help reset autoregulation prior to surgery

Question 28

_{PREOPERATIVE ANESTHETIC EVALUATION} Pre-op Manegment Poorly controlled diabetes

Answer 28

Manage BG levels prior to surgery Hyperglyvemia during surgery may enhance cerebral ischemia intra-op

Question 29

_{PREOPERATIVE ANESTHETIC EVALUATION} CAD is common in pts w/ Carotid artery dz - How should these two be managed when both are present?

Answer 29

Difficult sometimes to determine which dz to treat first Evaluation of severity of coronary artery disease and of carotid artery dz must be performed

Question 30

_{PREOPERATIVE ANESTHETIC EVALUATION} For which pts is carotid revascularization recommended before CABG?

Answer 30

Pts w/ symptomatic carotid dz Pts w/ bilateral severe asymptomatic carotid stenosis

Question 31

_{PREOPERATIVE ANESTHETIC EVALUATION} Which pre-op medications must be continued?

Answer 31

Beta-blockers Statins Antiplatelets

Question 32

_{PREOPERATIVE ANESTHETIC EVALUATION} Which pre-op medications must be held?

Answer 32

**Diuretics**

Question 33

_{PREOPERATIVE ANESTHETIC EVALUATION} General anesthesia versus Regional anesthesia

Answer 33

A choice must be made

Question 34

_{MONITORING DURING CAROTID ENDARTERECTOMY} Basic monitors

Answer 34

EKG, pulse ox, arterial blood pressure monitoring on contralateral side of surgery and leveled at the head to measure CPP CPP = MAP - ICP, normal 60-70 mmHg Anticipate BP fluctuations Have vasoactive drugs available (constrictors and dilators)

Question 35

_{MONITORING DURING CAROTID ENDARTERECTOMY} Cerebral perfusion monitors

Answer 35

EEG Stump pressure Somatosensory Monitoring Transcranial Doppler Cerebral oximetry Jugular venous bulb monitoring

Question 36

_{MONITORING DURING CAROTID ENDARTERECTOMY- Cerebral Perfusion Monitors} ”gold standard” for monitoring the adequacy of cerebral perfusion

Answer 36

**16-channel EEG**

Question 37

_{MONITORING DURING CAROTID ENDARTERECTOMY- Cerebral Perfusion Monitors} Limitations of the 16-channel EEG monitoring include:

Answer 37

High false positive rate False negative rate (esp. w/ previous strokes) Does not detect subcortical or small cortical infarct May impact readings in patients with previous stroke hx EEG monitoring can be affected by changes in temperature, blood pressure, and anesthesia dept (In fact, when using GETA, a stable physiologic and anesthetic depth are mandatory to ensure adequacy of EEG monitoring) May not be sensitive or specific enough to predict need for shunting

Question 38

_{MONITORING DURING CAROTID ENDARTERECTOMY- Cerebral Perfusion Monitors} What's the most effective means of assessing cerebral blood flow during carotid endarterectomy under “regional anesthesia” ?

Answer 38

**Keeping the patient awake!!!** Under “regional anesthesia” it states that keeping the patient awake allows for continuous neurological monitoring of the awake patient, which is considered to be the most sensitive method for detecting inadequate cerebral perfusion and function.

Question 39

MONITORING DURING CAROTID ENDARTERECTOMY- Cerebral Perfusion Monitors What do recent evidence show regarding EEG vs other methods to monitor Cerebral Perfusion Monitors?

Answer 39

No consistent data showing that EEG are superior to other methods

Question 40

_{MONITORING DURING CAROTID ENDARTERECTOMY} The ipsilateral retrograde perfusion pressure that results from collateral flow through circle of Willis from the contralateral carotid artery is also known as:

Answer 40

**Stump Pressure** Carotid stump pressure estimates hemispheric blood flow by measuring pressure in the carotid stump distal to the clamp. Stump pressure is more often used to determine whether or not a shunt should be placed intraoperatively.

Question 41

_{MONITORING DURING CAROTID ENDARTERECTOMY} What's the utility of Stump Pressure montitoring?

Answer 41

Used to evaluate the adequacy of CPP during carotid clamping, and whether collateral circulation is adequate enough to maintain CBF Used to determine whether a shunt will be needed to maintain cerebral perfusion

Question 42

_{MONITORING DURING CAROTID ENDARTERECTOMY} Which the Stump Pressure values are considered adequate?

Answer 42

Stump pressure should be \>45 mmHg, otherwise shunt is needed

Question 43

_{MONITORING DURING CAROTID ENDARTERECTOMY} What's a possible negative consequence of false negative values on Stump Pressure reading?

Answer 43

Can result in false negative values, which lead to unnecessary shunt placement Inexpensive and simple, so still used

Question 44

_{MONITORING DURING CAROTID ENDARTERECTOMY} What is Somatosensory monitoring (SSEP) based on?

Answer 44

Response of the sensory cortex to electrical impulses form peripheral sensory nerve stimulation Sensory cortex= risk of ischemia during carotid artery clamping

Question 45

_{MONITORING DURING CAROTID ENDARTERECTOMY} unlike EEG, SSEP are able to detect which type of ischemia?

Answer 45

Subcortical sensory pathway ischemia Able to detect subcortical sensory pathway ischemia unlike EEG

Question 46

_{MONITORING DURING CAROTID ENDARTERECTOMY} Which characteristic changes of SSEP occur with reduced CBF and ischemia?

Answer 46

Decreased amplitude Increased latency

Question 47

_{MONITORING DURING CAROTID ENDARTERECTOMY} Which may affect SSEP monitoring?

Answer 47

Anesthetic depth Temperature Blood pressure

Question 48

_{MONITORING DURING CAROTID ENDARTERECTOMY} T/F: SSEP monitoring may not be sensitive or specific enough to predict need for shunting

Answer 48

**True** False positives and negatives do occur

Question 49

_{MONITORING DURING CAROTID ENDARTERECTOMY} Which monitoring technique offers Continuous measurement of mean blood flow velocity and detection of microemboli (air or particulate matter) in the middle cerebral artery

Answer 49

**Transcranial doppler (TCD)** Most peri-op neuro deficits are thought to be thrombolic in origin, TCD has been shown to detect embolization in more than 90% of pts TCD can be difficult to impliment d/t high rates of technical failures, it has limited use in clinical settings TCD Can also be used post-operatively to monitor for cerebral hyperperfusion Technically difficult to implement d/t high rate of technical failures

Question 50

_{MONITORING DURING CAROTID ENDARTERECTOMY} Jugular Venous Bulb Monitoring

Answer 50

Refer to Module I and chapter reading

Question 51

_{MONITORING DURING CAROTID ENDARTERECTOMY} Cerebral Oximetry

Answer 51

Refer to Module I and chapter reading

Question 52

_{CAROTID ENDARTERECTOMY: GENERAL VS. REGIONAL} Regardless of the technique chosen, the ultimate anesthetic goals are

Answer 52

Maintain adequate cerebral perfusion of the brain Awake patient following surgery, so that a neuro exam can be immediately performed

Question 53

_{CAROTID ENDARTERECTOMY: GENERAL VS. REGIONAL} Common historical anesthetic technique for CEA was:

Answer 53

**Cervical plexus block** Historically, regional anesthesia, in the form of a cervical plexus block most commonly used Patients can be examined intraoperatively, more cost effective, shorter length of stay

Question 54

_{CAROTID ENDARTERECTOMY: GENERAL VS. REGIONAL} T/F: There is no statistical difference in perioperative death, MI, and stroke with regional anesthesia when compared to general anesthesia

Answer 54

**True** GALA trial showed no statistical difference in perioperative death, MI, and stroke when compared to general anesthesia The decision between regional vs general anesthesia for CEA varies by institution

Question 55

_{CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA} Advantages of using General Anesthesia for CEA include:

Answer 55

General reduces cerebral metabolic oxygen demands Better regulation of PaO2, PaCO2, and MAP under GA No specific technique is more superior than the other

Question 56

_{CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA} BP consideration when using General Anesthesia for CEA

Answer 56

Must anticipate swings in blood pressure and be prepared to treat accordingly Have Short acting vasoactive and vasodilating drugs available (Phenylepherine, NTG, Nicardipine) Specially important w/ Patients with poorly controlled HTN Have IV fluid for volume depletion Ready for meticulous titration of anesthetic gases Prompt treatment of hypotension is very important

Question 57

_{CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Induction} Limit benzodiazepine use - Why?

Answer 57

May prolong wake up time at the end Consider opioids for anxiety

Question 58

_{CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Induction} Typical hypnotic agent is

Answer 58

**Propofol** (Unless limited cardiac reserves, in which case use Etomidate) **Etomidate** (for patients with limited cardiac reserve)

Question 59

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Induction Which drugs can be used at induction (as adjuntc) to blunt hypertensive reaction to laryngoscopy?

Answer 59

Small dose Opioids or Beta-blockers

Question 60

_{CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA} Which inhalation agents have been shown to provides greatest protection against ischemia

Answer 60

**Isoflurane** (provides greatest protection against ischemia) **Sevoflurane** (similar protection against ischemia as Isoflurane)

Question 61

_{CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA} Which inhalation agent is appropriate in accelerating wakeup and allowing for more immediate neurological assessment?

Answer 61

**Desflurane** accelerates wakeup, allowing for more immediate neurological assessment

Question 62

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA Both N2O or Remifentanil appropriate - If N2O is used, it should be d/cd befored the carotid artery is openned. Why?

Answer 62

A small amount of air present in the artery could potentially expend and cause an arterial air embolism

Question 63

_{CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - MAINTENANCE} Consider low dose Opioids, especially if

Answer 63

surgeon using local anesthetic in field Not much pain experienced in such case

Question 64

_{CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - MAINTENANCE} BP and HR management

Answer 64

MAP maintained at or slightly above baseline Avoid tachycardia ^{(Beta-blockers if needed in small increments/consider shorter acting)}

Question 65

_{CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Other Considerations} What dose of Heparin would the surgeon request prior to clamping of the carotid artery?

Answer 65

Heparin **100 units/kg** prior to clamping of the carotid artery Reversal of Heparin with Protamine after procedure

Question 66

_{CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Other Considerations} Where should MAP be maintained during carotid clamping?

Answer 66

During carotid clamping, maintain MAP within 20%(+/-) of patient’s baseline

Question 67

_{CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Other Considerations} Watch for reflex bradycardia - why?

Answer 67

Surgical manipulation of the carotid sinus could cause reflex bradycardia Have Atropine available for treatment Surgeon main inflitrate the surgical site w/ lidcaine to prevent this from hapenning

Question 68

_{CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Other Considerations​} Maintain normocapnia (normal EtCO2) or mild hypocapnia during the procedure - why?

Answer 68

Hypercapnia can cause Steal phenomenon This shunts blood avay from the ischemic areas af the brain Theoretically, hypocapnia will vasoconstrict and has been advocated for as a reversal for the Steal phenomenon, however its benefits have not been proven clinically

Question 69

_{CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Other Considerations​} Keep glucose levels \< 180 mg/dl for diabetic pts - Why?

Answer 69

Studies show that BG levels \> 200 mg/dL on post op Day 1 corellate w/ increased risks for strokes, TIAs, MI, and Death

Question 70

_{CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Other Considerations​} Watch opioid administration, especially if surgeon injects local anesthetic - Why?

Answer 70

Not much pain associated with procedure,

Question 71

_{CAROTID ENDARTERECTOMY: REGIONAL ANESTHESIA} Historically done in the form of

Answer 71

Deep and superficial cervical plexus block C2 - C4 nerve roots This technique has been around for \> 40 yrs and many providers still prefer it

Question 72

_{CAROTID ENDARTERECTOMY: REGIONAL ANESTHESIA} Advantages of Deep and superficial cervical plexus block for CEA

Answer 72

Minimal sedation required Awake patient allows for continual neurological assessment, which is especially important during trial occlusion of the carotid artery –No adverse effect --\> continued procedure with RA –Adverse effect --\> shunt inserted &/or GA with ETT Less intraoperative hypotension Faster postoperative recovery and provides postop analgesia Lower cost

Question 73

_{CAROTID ENDARTERECTOMY: REGIONAL ANESTHESIA} What must be done if adverse effect occur with Deep and superficial cervical plexus block for CEA?

Answer 73

Shunt inserted &/or GA with ETT

Question 74

_{CAROTID ENDARTERECTOMY: REGIONAL ANESTHESIA} Disadvantages of using regional anesthesia for CEA include:

Answer 74

More intraoperative hypertension (a/w a higher release of catecholamines) Awkward airway control if need to convert to GA Sedation may obscure neurological monitoring (and cause hypercapnia and hypoxia) Patient discomfort (if the procedure is long of if ischemia develops) Sedation causing hypercapnia or hypoxia

Question 75

_{CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS} Post-operative **Hypertension** r/t

Answer 75

Surgical _denervation_ of **ipsilateral carotid baroreceptor** Especially in pts w/ poorly control HTN prior to surgery Regional anesthesia is a/w less hypertension May need Labetalol or Nicardipine or Sodium Nitroprusside post-operatively

Question 76

_{CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS} Carotid body denervation can also occur - What causes it? what could it lead to?

Answer 76

Caused by surgical manipulation May lead to impaired ventilatory response to mild hypoxemia

Question 77

_{CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS} Postoperative hoarseness and ipsilateral tongue deviation may occur - How does this happen?

Answer 77

Retractors use during the procedure to visualize the surgical field These retractors can put pressure on the recurrent laryngeal nerve or the hypoglossal nerve Careful in patients with hx of contralateral CEA or neck surgery Should subside shortly after surgery

Question 78

_{CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS} Monitor for postoperative wound hematoma - why?

Answer 78

Airway compromise is possible

Question 79

_{CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS} Postoperative Cerebral Hyperperfusion Syndrome may occur - What causes it?

Answer 79

Abrupt increase in amount of blood flow and loss of autoregulation to the reperfused brain Typically doesn't occur until several days after the procedure

Question 80

_{CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS} S/S of Postoperative Cerebral Hyperperfusion Syndrome include:

Answer 80

Headache, seizures, focal neurologic signs, brain edema, intracerebral hemorrhage

Question 81

_{CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS} Which pts are at increased risk for Postoperative Cerebral Hyperperfusion Syndrome?

Answer 81

Patients with severe postoperative HTN Patients with severe preoperative internal carotid artery stenosis

Question 82

_{CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS} Other post-op concerns following CEA include:

Answer 82

Postoperative hypotension Loss of carotid body function CEAs not associated with large blood loss of fluid shifts

Question 83

_{ENDOVASCULAR TREATMEBNT: CAROTID ARTERY STENTING} Endovascular treatment of carotid artery disease includes:

Answer 83

Percutaneous angioplasty & stenting

Question 84

_{ENDOVASCULAR TREATMEBNT: CAROTID ARTERY STENTING} Where are Percutaneous angioplasty & stenting procedures typically performed? which anesthetic technique is typically used?

Answer 84

Specialized endovascular suites under Local anesthesia with light sedation (to facilitate pt's comfort and the need for frequent neuro monitoring)

Question 85

_{ENDOVASCULAR TREATMEBNT: CAROTID ARTERY STENTING} Monitors used:

Answer 85

Routine monitors and arterial line

Question 86

_{ENDOVASCULAR TREATMENT: CAROTID ARTERY STENTING} Procedural approach

Answer 86

Femoral approach is standard Brachial and high radial arteries are alternative sites

Question 87

_{ENDOVASCULAR TREATMEBNT: CAROTID ARTERY STENTING​} Embolic protection devices are mandatory - why?

Answer 87

Provide protection in the form of a filter or an occlusive balloon

Question 88

_{ENDOVASCULAR TREATMEBNT: CAROTID ARTERY STENTING​} Antiplatelet therapy:

Answer 88

Dual Antiplatelet therapy​ is used along w/ self-expanding stent

Question 89

_{ENDOVASCULAR TREATMEBNT: CAROTID ARTERY STENTING​} How does endovascular tx compares to traditional CEA?

Answer 89

Unfortunately, endovascular tx has been shown to be inferior to the traditional CEA in outcome studies related to stroke and death rates Especially in pt \> 70 yo

Question 90

_{ENDOVASCULAR TREATMEBNT: CAROTID ARTERY STENTING​} In which outcome areas is endovascular tx superior to traditional CEA?

Answer 90

Reduced rates of myocardial infarction, cranial nerve palsy, and access site hematomas