carotid artery stenosis

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Pathology

* the circle of Willis usually maintains cerebral blood flow despite unilateral, or even bilateral carotid occlusion[25]

Clinical manifestations

Radiology

* sensitivity/specificity[9]

Complications

Management

* No benefit to more than 162 mg QD

* No indication to switch from aspirin to clopidogrel[3]

Clinical trials

More general terms

Additional terms

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1021-22
  2. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 2338
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2021
  4. Sila CA Carotid stenosis: current strategies for choosing between medical and surgical management. Cleveland Clin J Med 67:851, 2000 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11104336
  5. J Rapp, UCSF Fresno Invited Lecture, May 13, 1997
  6. 6.0 6.1 Journal Watch 22(17):134, 2002 {small sample, 106 patients} Nadareishvili ZG, Rothwell PM, Beletsky V et al Long-term risk of stroke and other vascular events in patients with asymptomatic carotid artery stenosis. Arch Neurol 59:1162, 2002 Arch Neurol. 2002 Jul;59(7):1162-6.
  7. 7.0 7.1 Journal Watch 23(6):48, 2003 Rothwell PM, Eliasziw M, Gutnikov SA et al Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 361:107, 2003 PMID: https://www.ncbi.nlm.nih.gov/pubmed/12531577
  8. 8.0 8.1 Journal Watch 24(6):49-50, 2004 Johnston SC, O'Meara ES, Manolio TA et al Cognitive impairment and decline are associated with carotid artery disease in patients without clinically evident cerebrovascular disease. Ann Intern Med 140:237, 2004 PMID: https://www.ncbi.nlm.nih.gov/pubmed/14970146
  9. 9.0 9.1 Wardlaw JM et al, Non-invasive imaging compared with intra-arterial angiography in the diagnosis of symptomatic carotid stenosis: A metananalysis. Lancet 2006; 367:1503 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16679163
  10. 10.0 10.1 Mas J-L et al for the EVA-3S Investigators Endearterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med 2006, 355:1660 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17050890
    SPACE Collaborative Group. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: A randomized non-inferiority trial. Lancet 2006, 368:1239 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17027729
    Roubin GS et al for the CREST investigators Surgery, stenting to open blocked neck arteries similar in safety, efficacy, but show differences in stroke, heart attack and death rates at certain ages: Abstract 197 American Heart Association/American Stroke Association American Stroke Association late-breaking science report: SAN ANTONIO, Feb. 26, 2010 http://americanheart.mediaroom.com/index.php?s=43&item=971
    International Carotid Stenting Study investigators Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial The Lancet, Early Online Publication, 26 February 2010 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/20189239 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2960239-5/abstract
  11. Wolf T et al, Screening for carotid artery stenosis: An update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2007, 147:860 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18087057
    U.S. Preventive Services Task Force. Screening for carotid artery stenosis: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2007, 147:854 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18087056
  12. 12.0 12.1 Li Y et al. Strokes after cardiac surgery and relationship to carotid stenosis. Arch Neurol 2009 Sep; 66:1091. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19752298
  13. Taylor AJ et al Extended-Release Niacin or Ezetimibe and Carotid Intima-Media Thickness www.nejm.org November 15, 2009 (10.1056/NEJMoa0907569) PMID: https://www.ncbi.nlm.nih.gov/pubmed/19915217 doi:10.1056/NEJMoa0907569. http://content.nejm.org/cgi/content/full/NEJMoa0907569
    O'Riordan M ARBITER 6-HALTS: HDL raising with niacin superior to ezetimibe. November 15, 2009. Heartwire http://www.theheart.org/article/1022265.do
    Prescriber's Letter 16(12): 2009 COMMENTARY: Ezetimibe vs. Niacin for Atherosclerosis: The ARBITER 6-HALTS Study PATIENT HANDOUT: What You Should Know About Niacin Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=251212&pb=PRL (subscription needed) http://www.prescribersletter.com
  14. ICSS Investigators. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): An interim analysis of a randomised controlled trial. Lancet 2010 Mar 20; 375:985. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20189239 Bonati LH et al New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy of the International Carotid Stenting Study (ICSS). Lancet Neurol. 2010 Apr;9(4):353-62 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20189458
    Rothwell PM. Carotid stenting: More risky than endarterectomy and often no better than medical treatment alone. Lancet 2010 Mar 20; 375:957. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20304225
  15. Carotid Stenting Trialists' Collaboration. Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: A preplanned meta-analysis of individual patient data. Lancet 2010 Sep 25; 376:1062. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20832852
  16. 16.0 16.1 16.2 16.3 16.4 Brott TG et al. 2011 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: Executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Developed in collaboration with the American Academy of Neurology and Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2011 Feb 22; 57:1002. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21288680
  17. 17.0 17.1 17.2 The National Institutes of Health. Clinical Alert: Angioplasty combined with stenting plus aggressive medical therapy vs. aggressive medical therapy alone for intracranial arterial stenosis. NINDS stops trial enrollment due to a higher risk of stroke and death in the stented group. Apr 11 , 2011. http://www.nlm.nih.gov/databases/alerts/intracranial_arterial_stenosis.html
  18. 18.0 18.1 Journal Watch, Massachusetts Medical Society Sept 15, 2011
    Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. J JAMA 1995 May 10; 273:1421 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/7723155 <Internet> http://jama.ama-assn.org/content/273/18/1421.abstract
    Halliday A et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: Randomised controlled trial. Lancet 2004 May 8; 363:1491 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/15135594 <Internet> http://dx.doi.org/10.1016/S0140-6736(04)16146-1)
    Redgrave JN and Rothwell PM. Asymptomatic carotid stenosis: What to do. Curr Opin Neurol 2007 Feb; 20:58 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/17215690 <Internet> http://journals.lww.com/co-neurology/Abstract/2007/02000/Asymptomatic_carotid_stenosis__what_to_do.11.aspx
    Marquardt L et al. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: A prospective, population-based study. Stroke 2010 Jan; 41:e11 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19926843 <Internet> http://dx.doi.org/10.1161/STROKEAHA.109.561837
    Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: Results of a systematic review and analysis. Stroke 2009 Oct; 40:e573 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19696421 <Internet> http://dx.doi.org/10.1161/STROKEAHA.109.556068
    Topakian R et al. Ultrasonic plaque echolucency and emboli signals predict stroke in asymptomatic carotid stenosis. Neurology 2011 Aug 23; 77:751 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21849657 <Internet> http://dx.doi.org/10.1212/WNL.0b013e31822b00a6
    Madani A et al. High-risk asymptomatic carotid stenosis: Ulceration on 3D ultrasound vs TCD microemboli. Neurology 2011 Aug 23; 77:744 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21849642 <Internet> http://dx.doi.org/10.1212/WNL.0b013e31822b0090
    Marquardt L and Barnett HJM. Carotid stenosis: To revascularize, or not to revascularize. That is the question. Neurology 2011 Aug 23; 77:710. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21849648
  19. 19.0 19.1 Powers WJ et al. Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: The Carotid Occlusion Surgery Study Randomized Trial. JAMA 2011 Nov 9; 306:1983. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22068990
  20. 20.0 20.1 Lorenz MW et al. Carotid intima-media thickness progression to predict cardiovascular events in the general population (the PROG-IMT collaborative project): A meta-analysis of individual participant data. Lancet 2012 Jun 2; 379:2053. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22541275
  21. 21.0 21.1 Antoniou GA et al Meta-analysis and Meta-Regression Analysis of Outcomes of Carotid Endarterectomy and Stenting in the Elderly. JAMA Surg. Published online October 23, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24154858 <Internet> http://archsurg.jamanetwork.com/article.aspx?articleid=1757343
    Darling RC Carotid Intervention in the Elderly. Who Is Old and Who Benefits? JAMA Surg. Published online October 23, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24154829 <Internet> http://archsurg.jamanetwork.com/article.aspx?articleid=1757342
  22. Brott TG, Hobson RW 2nd, Howard G Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010 Jul 1;363(1):11-23 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20505173
  23. 23.0 23.1 Jonas DE et al Screening for Asymptomatic Carotid Artery Stenosis: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med. Published online 8 July 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25004169 <Internet> http://annals.org/article.aspx?articleid=1886688
    LeFevre ML et al. Screening for asymptomatic carotid artery stenosis: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014 Jul 8; PMID: https://www.ncbi.nlm.nih.gov/pubmed/25003392
    Goldstein LB Screening for Asymptomatic Carotid Artery Stenosis: Caveat Emptor. Ann Intern Med. Published online 8 July 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25003272 <Internet> http://annals.org/article.aspx?articleid=1886689
    US Preventive Services Task Force Screening for Asymptomatic Carotid Artery Stenosis. US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(5):476-481 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33528542 https://jamanetwork.com/journals/jama/fullarticle/2775719
    Guirguis-Blake JM, Webber EM, Coppola EL Screening for Asymptomatic Carotid Artery Stenosis in the General Population. Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2021;325(5):487-489 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33528528 https://jamanetwork.com/journals/jama/article-abstract/2775704
    Chaturvedi C. To Screen or Not to Screen for Carotid Stenosis. Is That the Question? JAMA Neurol. Published online February 2, 2021. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33528557 https://jamanetwork.com/journals/jamaneurology/article-abstract/2776047
  24. 24.0 24.1 24.2 Grotta JC. Carotid stenosis. N Engl J Med. 2013;369:1143-1150 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24047063
  25. 25.0 25.1 25.2 Yang C, Bogiatzi C, Spence JD Risk of Stroke at the Time of Carotid Occlusion. JAMA Neurol. Published online September 21, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26389542 <Internet> http://archneur.jamanetwork.com/article.aspx?articleid=2442470
    Chaturvedi S, Sacco RL Are the Current Risks of Asymptomatic Carotid Stenosis Exaggerated? Further Evidence Supporting the CREST 2 Trial. JAMA Neurol. Published online September 21, 2015. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26390399 <Internet> http://archneur.jamanetwork.com/article.aspx?articleid=2442469
  26. 26.0 26.1 Brott TG et al Long-Term Results of Stenting versus Endarterectomy for Carotid-Artery Stenosis. N Engl J Med. February 18, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26890472 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1505215
    Spence JD, Naylor AR Endarterectomy, Stenting, or Neither for Asymptomatic Carotid- Artery Stenosis. N Engl J Med. February 18, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26890473 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1600123
  27. 27.0 27.1 Howard G et al. Association between age and risk of stroke or death from carotid endarterectomy and carotid stenting: A meta-analysis of pooled patient data from four randomised trials. Lancet 2016 Feb 12; PMID: https://www.ncbi.nlm.nih.gov/pubmed/26880122
  28. 28.0 28.1 Rosenfield K, Matsumura JS, Chaturvedi S et al. Randomized trial of stent versus surgery for asymptomatic carotid stenosis. N Engl J Med 2016 Mar 17; 374:1011 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26886419 Free Article
  29. 29.0 29.1 Rantner B, Kollerits B, Roubin GS et al. Early endarterectomy carries a lower procedural risk than early stenting in patients with symptomatic stenosis of the internal carotid artery: Results from 4 randomized controlled trials. Stroke 2017 Jun 48:1580 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28455318 <Internet> http://stroke.ahajournals.org/content/48/6/1580
  30. 30.0 30.1 Anand SS, Bosch J, Eikelboom JW et al. Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: An international, randomised, double-blind, placebo-controlled trial. Lancet 2017 Nov 10; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29132880 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32409-1/fulltext
    Berger JS. Antithrombotic therapy in peripheral artery disease. Lancet 2017 Nov 10; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29132877 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32847-7/fulltext
  31. 31.0 31.1 Keyhani S, Cheng EM, Hoggatt KJ et al. Comparative effectiveness of carotid endarterectomy vs initial medical therapy in patients with asymptomatic carotid stenosis. JAMA Neurol 2020 Jun 1 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32478802 Free PMC article. https://jamanetwork.com/journals/jamaneurology/fullarticle/2766571
  32. Chang RW et al. Incidence of ischemic stroke in patients with asymptomatic severe carotid stenosis without surgical intervention. JAMA 2022 May 24/31; 327:1974-1981. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35608581 PMCID: PMC9131743 Free PMC article https://jamanetwork.com/journals/jama/fullarticle/2792617
  33. 33.0 33.1 Reiff T et al. Carotid endarterectomy or stenting or best medical treatment alone for moderate-to-severe asymptomatic carotid artery stenosis: 5-year results of a multicentre, randomised controlled trial. Lancet Neurol 2022 Oct; 21:877. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36115360 https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(22)00290-3/fulltext

Patient information

carotid artery stenosis patient information