Medical managementRisk factors for developing plaque buildup in the carotid arteries include hypertension, diabetes, high cholesterol, and smoking. All patients with evidence of any degree of carotid disease need aggressive medical management. Antiplatelet therapy with aspirin reduces the risk of stroke and heart attack. Tobacco cessation is vital. Control of cholesterol with medications called statins reduces the risk of both heart attack and stroke. Diabetes management is instrumental in preventing stroke and progression of disease.
Perhaps the most important risk factor to control is hypertension. The risk of stroke increases threefold when the systolic blood pressure exceeds 160 mmHg. According to recent reviews, even a modest lowering in blood pressure of 10 mmHg systolic and 3-6 mmHg diastolic reduces the risk of stroke by 30% and 42%.
Despite excellent medical management some patients continue to have strokes. This tends to occur in those patients who have had strokes in the past and those with more extensive carotid blockages.
Carotid surgery reduces stroke risk
Medical therapy alone may not be sufficient to reduce the risk of stroke. In patients who have already suffered a stroke and have a carotid stenosis greater than 50%, the two-year risk of recurrent stroke is 26%. Carotid endarterectomy can reduce the two-year risk of stroke to 9% after the surgical correction.
For patients with carotid disease who have not had previous symptoms, the risk of stroke increases significantly when the stenosis is greater than 80%. For these individuals, CEA reduces the risk of stroke from 11% down to 5% after 2-3 years.
While surgical revascularization has shown benefit, not all patients can tolerate anesthesia and surgery because they have other major illnesses. Furthermore, the above benefits are present only in the hands of skilled surgeons. Patients with coronary heart disease, chronic obstructive pulmonary disease, and prior neck surgery are examples of those at increased risk from carotid surgery. Because of the need for less invasive revascularization, carotid stenting technology was developed.
Stents right for some patients
Recently, carotid stenting has been developed as an alternative to carotid surgery in selected patients. Performed under x-ray guidance, a catheter is advanced from an artery in the leg, through the aorta, and into the carotid artery. Awire with a protective filter or mesh is placed beyond the blockage. The narrowing is opened with a balloon and a stent placed to keep the artery open (see figure 2). The protective apparatus traps any debris that may have been dislodged during the procedure. One study in patients at highrisk for surgery showed that carotid stenting is at least equivalent and likely better than surgery because of a decreased risk of heart attacks.
Reviewed by Francine Kaufman, M.D., 04/08
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