Carotid endarterectomy. Which patients can benefit?

Carotid endarterectomy for carotid artery stenosis is valuable for some patients, but not all. Results of clinical trials in symptomatic and asymptomatic patients provide guidance on use of this common vascular procedure. The authors of this article describe the controversies and concerns with the procedure and give their recommendations based on study results.     

Carotid stenting for impending carotid blowout: suitable supportive care for head and neck cancer patients?

BACKGROUND: Carotid blowout (CB) represents a dramatic end-of-life situation for palliative head and neck cancer patients, their relatives and caregivers. Recently, endovascular therapy has been proposed for head and neck surgical patients. Preliminary reports showed a better outcome with less morbidity compared to the previous treatment modalities. However, the specific use of such techniques for palliative head and neck cancer patients has not been previously described. METHOD: Retrospective review of two cases of head and neck cancer patients receiving palliative care, presenting with a CB, managed with endovascular stent placement. RESULTS: Bleeding was effectively stopped by the procedure in both cases. Both patients developed a post-procedure thromboembolism, which was immediately treated by appropriate anticoagulation therapy. Neurological symptoms resolved within 24 hours allowing rapid hospital discharge. One patient died at home seven months later. The second patient is alive five months after the procedure. No recurrence of CB occurred in either patient. CONCLUSIONS: Endovascular stent placement for CB allows a rapid arrest of bleeding and permits the use of anticoagulation therapy in order to avoid long-term neurological injury. In our view, carotid stenting should be considered as valid supportive care for palliative head and neck patients presenting with a CB.     

Should statins be given routinely before carotid endarterectomy?

Statins belong to a class of drugs known to inhibit 3-hydroxy 3-methylglutaryl coenzyme A (HMG CoA) reductase, and block hepatic cholesterol synthesis. Statins have been found to be highly effective in primary and secondary stroke prevention among medically managed patients with cardiovascular disease, and it appears that this benefit is largely owing to the non-cholesterol-lowering, so called pleiotropic, effects of statins. Over the past decade, agents such as beta-blockers, aspirin, or other antiplatelet medications have proven to reduce the incidence of adverse postoperative outcomes among vascular surgical patients and have rightfully assumed a place in our overall therapeutic armamentarium. There is growing evidence that statins may be especially effective in reducing cardiovascular morbidity and improving outcome following major vascular surgery. A recent study from Johns Hopkins Hospital demonstrated a threefold reduction in the rate of perioperative stroke (P < .05) and fivefold reduction of perioperative mortality (P < .05) among 1566 patients undergoing carotid endarterectomy (CEA). This benefit was confirmed in a series of 3360 CEAs performed at multiple hospitals throughout western Canada. Statin use was independently associated with a 75% reduction (OR: 0.25; 95%CI: 0.07-0.90) in the odds of death and a 45% reduction (OR: 0.55; 95% CI: 0.32-0.95) in the odds of ischemic stroke or death among patients with symptomatic carotid disease. A number of the pleiotropic effects of statin medications may be responsible for these clinical observations. Further work is necessary to better elucidate these mechanisms, as well as to determine the optimal agents, dosing, and timing of drug administration among patients undergoing carotid interventions. Nevertheless, in light of these data a strong case can be made to start patients on statin medications prior to CEA if time permits.     

Which patients benefit from carotid stenting? What recent trials show

So far, angioplasty with stenting of the carotid arteries does not seem to offer any clear advantage over traditional carotid endarterectomy for patients with symptomatic or asymptomatic stenosis. This paper reviews recent and ongoing studies of carotid revascularization, with conclusions on how these treatments should be used, based on what we know now.     

What are the skills that prepare vascular surgeons for carotid stenting?

Although it has been clearly established that in certain groups of patients, such as in patients with symptomatic high-grade carotid stenosis and in selected asymptomatic patients with high-grade stenosis, carotid endarterectomy offers significant protection from stroke compared with medical therapy, the role of carotid stenting in this patients versus carotid endarterectomy is undergoing a rapid evolution. The definitive evidence awaits the results of ongoing prospective, randomized trials such as CREST and others, but it is clear that carotid stenting will increasingly occupy a significant role in the therapy of carotid bifurcation disease. In that context, vascular surgeons, traditionally the experts on the management of this condition, face the specter of other disciplines intervening in its treatment. In addition, if vascular surgeons do not acquire the skills and the expertise necessary to perform carotid stenting, it is self-evident that they run the risk of being spectators rather retaining the mantle of expert in the management of carotid bifurcation disease. As such, it is the duty of vascular surgeons to acquire the skills with which to retain their rightful place in its management and treatment. The purpose of this article is to describe the skills necessary to become competent in the endovascular management of carotid disease, offer some thoughts and strategy by which one can gain experience and develop an armamentarium of skills necessary to perform carotid stenting, and offer a comprehensive array of options of management and treatment to the patient with carotid disease.     

What is the latest in inventory for carotid stenting and cerebral protection?

Carotid angioplasty is fast being incorporated into the treatment options for patients with carotid occlusive disease. The results of the SAPPHIRE and ARCHER trials have demonstrated that carotid angioplasty and stenting with the use of cerebral protection devices is not inferior to open surgical endarterectomy in high-risk patients. The limiting step for percutaneous carotid interventions was the potential for cerebral embolization during the intervention. However, the ready availability of several embolic protection devices has placed this technology into the hands of many endovascular specialists. A brief outline of the basic inventory necessary for a carotid stent program is presented.     

Antioxidant supplements to prevent heart disease. Real hope or empty hype?

Antioxidants in foods and supplements are being widely promoted for their health benefits. Protection from heart disease is one claim that seems compelling in light of scientific evidence and large-scale observational studies. But will antioxidant supplements help your patients? To examine this question, Dr Tran reviews numerous clinical studies and evaluates the discrepancies between observational and clinical results.     

Why to operate on the carotid artery?

AIM, METHODS, PATIENTS: In a prospective interdisciplinary study of 468 carotid artery stenoses we compared the ultrasound plaque morphology with the histological diagnosis. RESULTS: For detection of soft plaques and hard plaques by preoperative ultrasound examination we found a sensitivity of 80%. The accuracy for the estimation of the degree of the stenosis was 98%. In case of stroke in progression and completed stroke we found ulcerations by histological examination in 72%. By ultra-sound these ulcerations were detected only in 53%. We found a significant higher figure for TIA and stroke in soft plaque patients than in asymptomatic stage, in which hard plaque formation was seen more often. CONSEQUENCES: Patients with a soft plaque seem to have a higher risk of a postoperative permanent neurological deficit. However, the dangerous plaque formation with thrombosis or ulceration was not be detected with appropriate accuracy. Therefore the risk of embolisation cannot be predicted sufficiently by means of duplex scanning. This would be extremely important for the indication for stenting in this area. The number of HITS (high intensity transient signals) is 8 to 20 times higher in carotid stenting.