Chapter 90 - Nonatherosclerotic carotid artery disease

Question 1

Rate of carotid stenosis after radiotherapy

Answer 1

25% (16-55)

Question 2

Rate of restenosis after CEA if radiation done before

Answer 2

6%

Question 3

Rate of CVA after neck radiation 15 year rate

Answer 3

2.6% vs 0.29% of control 15 year = 12%

Question 4

Pathophysiology of radiation carotid stenosis

Answer 4

1) endothelial cell and vasa vasorum swell, vacuolization, vesicle formation 2) platelet aggregation and fibrin 3) obstructed lumen in vasa vasorum 4) focal necrosis and fibrosis of media 5) periadventitial fibrosis 6) NO and prostacyclin-mediated endothelium-dependent relaxation impaired 7) long term effect due to sustained activation of TNF kappaB

Question 5

Difference between radiation plaque and atherosclerotic plaque

Answer 5

1) Radiation more stable 2) less macrophage infiltrate 3) smaller lipid core 4) lesion in CCA and distal ICA

Question 6

Carotid artery intima-media thickness (CIMT) seen after radiation doses greater than

Answer 6

35 Gy

Question 7

Factors favoring different carotid treatment modalities

Answer 7

TABLE 90.1

Question 8

Pec major myocutaneous flap for carotid

Answer 8

1) elliptical skin and soft tissue flap created 2) attachment of pec major divided from anterior chest wall, sternum and clavicle 3) rotate 180 onto thoracoacromial pedicle 4) advance through subcutaneous tunnel to incision in neck

Question 9

Metaanalysis on radiation carotid 30 d mortality, stroke for symp and asymp for CAS and CEA

Answer 9

SYMPTOMATIC 30d mortality 2.6% CEA 5.1% CAS 30d stroke and death 2.7% CEA vs 5.1% CAS ASYMPTOMATIC 30d mortality 0% CEA 1.4% CAS stroke and death 1.1% CEA 2.3% CAS

Question 10

Permanent nerve palsy in CEA after radiation

Answer 10

0.6%

Question 11

Restenosis after radiation carotid treatment

Answer 11

CAS 18% CEA 10%

Question 12

Restenosis after regular carotid disease treatment

Answer 12

CAS 2-31% CEA 3-12% over 2-5 years

Question 13

Restenosis > 70% 5 year risk of CVA

Answer 13

23%

Question 14

Risk of restenosis

Answer 14

1) age 2) female 3) head and neck cancer 4) diabetes 5) smoking 6) dyslipidemia 7) residual stenosis after stent 8) larger number of stents

Question 15

Restenosis after CEA primary vs patch use

Answer 15

5x more if primary

Question 16

Trials that looked at restenosis between CEA anc CAS

Answer 16

TABLE 90.3

Question 17

Proposed duplex criteria for in-stent carotid stenosis

Answer 17

TABLE 90.4 no consensus

Question 18

Threshold to treat restenosis

Answer 18

> 50% if symptomatic and good risk patient > 80% if asymptomatic

Question 19

Fokkema meta analysis on CEA to CAS after restenosis CEA

Answer 19

1) 1132 patients 2) CEA younger, more symptomatic and more smokers 3) CAS more HTN, renal failure and antiplatelets 4) no difference in outcome of stroke, death or combined 2.7 vs 2.3% 5) no difference between symp and asymp 6) CN injury 5.5%, bleed 2.7% and wound infection 0.2% higher in CEA 7) access complication 1.9% CAS 8) tech failure CAS 1.3%

Question 20

Tu meta analysis on CEA vs CAS after restenosis CEA

Answer 20

1) 4399 patients 2) no difference in post-op stroke 3) DN injury 6%; 80% resolve in 3 months 4) restenosis at 5 years 4.4% vs 13.5% of CAS