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Endovascular Treatment of Carotid Artery Disease

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Catheter-Based Cardiovascular Interventions

Abstract

Carotid artery disease is responsible for some 20% of all thromboembolic strokes. Among the modes of stroke prevention, carotid stent angioplasty represents the latest option available since the late 1970s as carotid artery angioplasty and since the early 1990s as carotid artery stenting. Although stenting and the older carotid artery endarterectomy available since the early 1950s are in a number of patients competitive treatment options, both means provide important advantages in individual patients presenting with specific adversities. For example, while large plaque burden, heavy calcification, and extreme tortuosity may favor surgery, in cases with excessive surgical risk, high proximal lesions and status postradiation of the neck stenting might be the preferable means of carotid revascularization. Due to the major advances in instrumentation and technology, the interventionists may choose from a variety of carotid artery stent designs and protection devices. The procedure is performed following the established institutional protocol implementing the current guidelines. Continuous monitoring of outcomes represents an important component of internal and external quality assurance. The endovascular approach is also used for treatment of carotid artery aneurysms of different pathogenesis. A new development is combined carotid angioplasty, stent placement, and thrombectomy in patients with acute stroke.

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  1. Radiologische Klinik, Klinikum Dortmund, Dortmund, 44123, Germany

    Klaus Mathias M.D.

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  1. Klaus Mathias M.D.
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Correspondence to Klaus Mathias M.D. .

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  1. , Dept. of Internal Medicine, Gesundheitszentrum Bitterfeld-Wolfen, Friedrich-Ludwig-Jahn-Straße 2, Bitterfeld-Wolfen, 06749, Germany

    Peter Lanzer

Appendix

Appendix

1.1 Standard Protocol

Complete diagnostic selective four vessel cerebral angiography is recommended in all patients suggested for revascularization to document the baseline status including functional anatomy of the circle of Willis and to exclude presence of associated distal lesions. The invasive angiogram can be replaced by CT or MR angiogram which should include the aortic arch and cerebral arteries. Following identification of carotid artery lesion and indication for revascularization based on accepted criteria, the treatment modality is selected, ideally resulting from a consensus between interventionist, vascular surgeon, and neurologist. The selected treatment option is presented and explained in detail to the patient, and informed consent is obtained.

Prior to the procedure, the patient should receive dual antiplatelet therapy, if possible for several weeks. The day before the scheduled intervention, neurological examination performed by a neurologist and MR brain scan are performed.

On the day of the intervention, the patient is kept NPO (nothing per mouth), intravenous line is established, and hydration with crystalline solution such as normal saline is started. In predisposed patients, urethral catheter may be placed. In neurologically unstable patients, the options of sedation and intubation are discussed with the anesthesiologist and implemented as needed.

Following the placement of the sheath, typically 5,000 IU unfractioned heparin is administered intravenously. During the intervention, patient’s neurological status is continuously monitored by verbal contact and if needed examination of motor functions. From the beginning of the procedure, volume is supplemented using colloid solution, and blood pressure is preferably controlled by additional volume supplementation. Only in patients with profound hypotension, low-dose catecholamines may be employed. Particularly during the stent deployment and postdilatation, transient bradycardia or asystole may develop rapidly responsive to 0.5 mg atropine bolus administration that can be repeated if needed.

When the patient is free of adverse events, the sheath is withdrawn and the puncture site is closed using a closure device.

On the first day after the procedure, neurological examination performed by a neurologist and MR brain scan are performed. In absence of complications, the patient is discharged on the day after the procedure. Clinical and color duplex follow-ups in 3 and 6 months and yearly thereafter are recommended.

The standard protocols should be established in all centers providing carotid artery revascularization services. The adopted protocols may be modified according to the individual center structure and organization. In all cases, the current guidelines should be reviewed and implemented.

ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. J Am Coll Cardiol 2011;57:16–94.

ESC guidelines on the diagnosis and treatment of peripheral artery disease. Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Eur Heart J 2011;2–56. http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/Guidelines-peripheral-AD-FT.pdf. Accessed 29 Dec2011.

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Mathias, K. (2013). Endovascular Treatment of Carotid Artery Disease. In: Lanzer, P. (eds) Catheter-Based Cardiovascular Interventions. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-27676-7_51

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