Peripheral artery disease (PAD) pt 2 Flashcards
(15 cards)
Should you screen for carotid artery stenosis in the general adult population?
No
Carotid stenosis epidemiology:
1) What is the 2nd leading cause of death world-wide and 4th in USA?
2) What causes up to 15% of these?
3) What are the risk factors?
1) Stroke
2) Up to 15% of strokes are caused by atherosclerotic stenosis (ischemia) of the internal carotid or intracranial arteries
3) Same as other ASCVD conditions
-HTN, DM, Lipids, Smoking
Carotid auscultation is also not useful to diagnose or r/o carotid artery stenosis; why?
1) “Bruits” commonly referred from heart or external carotid, venous hum, and tortuous arteries
-Poor correlation between severity of stenosis and bruits
-Bruit does not correlate with stroke risk
What are some Sx of carotid stenosis?
history of TIA, amaurosis fugax, or stroke in distribution of affected artery
Carotid stenosis:
Most common pathology associated with internal carotid artery sourced emboli are what? Explain
1) Anterior circulation: both motor and sensory symptoms
-Anterior and middle cerebral arteries (ACA + MCA)
2) Amaurosis fugax: transient blindness
Describe the 2 main parts of Symptomatic Carotid stenosis Evaluation
1) Duplex US: Detecting and grading stenosis at carotid bifurcation
2) MRA or CTA: add to US to show plaque morphology, intracranial collateralization, and brain perfusion that can affect stroke risk
What do the results of imaging regarding carotid stenosis mean?
1) Without surgical intervention
-Current studies indicate annual stroke rate ~ 1% in patient with carotid artery stenosis of 70% or more who received GDMT intervention
2) Surgical benefit less clear
What are the Txs for carotid stenosis in asymptomatic pts?
1) ASA 81 mg daily
2) Statin therapy daily
3) Optimize other co-morbid conditions
Smoking cessation, HTN, T2DM….
Carotid endarterectomy: Asymptomatic patients with _____% or more stenosis may have small benefit in stroke reduction if low surgical risk, reduction of ~ 1% per year
60%
Carotid endarterectomy: Carotid endarterectomy within 2 weeks of symptom onset and carotid artery stenosis > 50% reduces risk of stroke: NNT =what?
5 over 5 years
Carotid endarterectomy: Describe which symptomatic pts it’s indicated for (anterior circulation, TIA or minor stroke)
1) Indicated in patients with carotid artery stenosis of 70-99%
2) In patient with low surgical risk, modest benefit in 50-69% stenosis
3) In symptomatic patients with less than 50% stenosis, medical management with antiplatelet therapy (ASA, Clopidogrel) and risk factor modification are recommended
Carotid endarterectomy: Describe the benefits and cons
1) Less benefit with longer symptoms to surgery
2) Short term complication rate – 7% of patients experiencing stroke or death within 30 days
Stroke within 30 days of carotid endarterectomy dramatically increases mortality
3) 15% of patients experience stroke or death within 5 years of the procedure
Describe Revascularization carotid stenosis
1) Stenting of carotid stenosis
> 70 y/o stenting has more short-term (within 3 months) complications than endarterectomy
70 y/o or less, the risk of stenting vs endarterectomy is equal
2) After 3 months, stenting and endarterectomy is equivalent in all
Carotid stenosis: What is the AHA acceptable rate of intervention complications?
1) Asymptomatic < 3%
2) Symptomatic:
TIA < 5%
Stroke < 7%
3) Higher rates negate benefit of interventions
List and describe 2 intervention complications of carotid stenosis
1) Cranial nerve injuries
Most common
CN IX (glossopharyngeal – carotid sinus n.), X (Vagus – recurrent laryngeal n.), XI (spinal accessory – motor to SCM and trap m.), XII (hypoglossal – motor to extrinsic muscles of tongue) (jugular foramen and hypoglossal canal, carotid sheath)
2) Stroke – embolization or carotid occlusion
Most feared
