Question

Indications for carotid endarterectomy.

Hint:

Carotid endarterectomy is a proven procedure for preventing stroke in patients with symptomatic or severe asymptomatic carotid stenosis, but patient selection is key to ensuring optimal outcomes.

Answer 1

Carotid endarterectomy (CEA) is a surgical procedure used to remove atherosclerotic plaques from the carotid arteries to prevent stroke. It is typically performed in patients with symptomatic or asymptomatic carotid stenosis to reduce the risk of stroke.
Step 1: Indications for Carotid Endarterectomy:
1. Symptomatic Carotid Stenosis: CEA is indicated for patients with symptomatic carotid stenosis (i.e., those who have had a transient ischemic attack or stroke due to the stenosis) with a greater than 50% narrowing of the carotid artery. The procedure reduces the risk of recurrent stroke in these patients.
2. Asymptomatic Carotid Stenosis: CEA may also be performed in patients with asymptomatic carotid stenosis, especially if the stenosis is greater than 70%, in order to reduce the risk of future stroke. This decision is made based on individual risk factors and the patient's overall health.
3. High-Risk Features: CEA may be considered in patients with high-risk features, such as a history of contralateral stroke or significant progression of stenosis despite medical therapy.
Step 2: Preoperative Evaluation:
1. Imaging Studies: Patients considered for CEA should undergo carotid ultrasound, CT angiography, or MR angiography to accurately assess the degree of stenosis and plaque morphology.
2. Cardiac Evaluation: A cardiac evaluation is essential to assess for any contraindications to surgery, such as uncontrolled arrhythmias or heart disease.
Step 3: Contraindications to Carotid Endarterectomy:
1. Severe Medical Comorbidities: CEA is generally not recommended for patients with severe comorbidities that would increase the risk of surgery, such as end-stage renal disease or advanced cancer.
2. Total Occlusion: Carotid endarterectomy is not effective in patients with complete occlusion of the carotid artery, as the procedure would not improve blood flow to the brain.
3. High Surgical Risk: Patients with a high risk of perioperative complications, such as those with severe pulmonary or cardiac disease, may not be suitable candidates for CEA.