Carotid Artery Stenosis Presentation by: Megan Burk, SPT

Outline Background Carotid Artery Stenosis Interesting Stats Tx’s (Revascularization) Stent/Angioplasty Recommendations/Indications Endarterectomy Endarterectomy VS stent Rehab- Preventative Care

Carotid Artery Stenosis Cause: Artery narrowing due to atherosclerosis; most common at bifurcation1 Moderate: 50%-69% stenosis1 Severe: 70%-99% stenosis1 Symptomatic: TIA or stroke Asymptomatic: Usually found incidentally or upon follow-up of abnormal auscultation on a physical exam1

Carotid Artery Stenosis Prevalence: <10% of the population has asymptomatic carotid artery stenosis of at least %50 or more1 Risk factors: People 65 y/o, CAD, PVD, DM, HTN, dyslipidemia, or risk factors for CVD1 Males affected 2:1 for asymptomatic carotid stenosis1

Interesting Stats ~35% of people who have TIAs will have a stroke within 5 years2 Of all strokes within the adult population, carotid stenosis is responsible for 20%. 3 In the U.S.:4 Stroke is #5 /10 top causes of death Over 795,000 have a stroke every year In 2009, 24% people that were in the hospital for a stroke were under 65 y/o

Revascularization methods Includes: Stent or endarterectomy Should be performed within 2 weeks of a TIA or stroke1 Indicated for patients with:1 Stenosis >50% No total occlusion No severe disability 2’ to infarct Other treatment methods: Medication therapy Treat risk factors

Stent Anatomy of vessels must be considered3 Considered an alternative to endart Stent preferred over endart if pt has:1 Uncorrectable CAD, heart failure, or COPD Scar tissue/fibrosis from prior procedure Prior cranial nerve injury Any lesion from body of C2 to clavicle

Endarterectomy Patients should be offered “endarterectomy as first choice, with carotid artery stenting reserved for patients at high surgical risk.” 3 Endart preferred over stent especially if:1 >70 y/o Lesions >15 mm

Endarterectomy VS stent 2014 study by Spangler5 et al. compared normal and high-risk cohorts of symptomatic vs asymptomatic patients. Large sample size: 11,880 patients 11,366 underwent endart & 544 underwent stent Normal risk: patients that fell under the lower 3 quartiles of risk score (based on 5-year mortalities risk score) High risk: Calculated by mortality risk score and a patient that has had CHF, open-heart sx within 6 weeks, recent MI, unstable angina, severe pulmonary disease, and age over 80 y/o. Results: For asymptomatic patients (normal and high risk): No significant difference between stent and endarterectomy revascularization outcomes in terms of in-hospital stroke and/or death For symptomatic patients: Significant difference: patients that had a stent had worse outcomes with death, stroke, and MI than patients after an endarterectomy. Normal risk patients had stroke or death rate of 1.3% with endart and 5.2% with stent. High risk patients had stroke or death rate of 1.5% with endart and 9.3% with stent.

Endarterectomy VS stent Results: No significant difference between endart and stent with intermediate to long-term all endpoint outcomes. Significant differences between short-term outcomes: Stroke or death rates: Endart: 5.4% Stent: 7.3% MI incidence rates (weighted from 4 trials): Endart: 2.6% Stent: 0.9% Cranial neuropathy Endart: 7.5% Stent: <1% <0.5% are permanent 2010 meta-analysis by Meier3 et al. included 11 articles comparing endart and stent for treating carotid artery stenosis (symptomatic or asymptomatic patients) and included short- term and intermediate to long- term outcomes of stroke, death, MI, facial neuropathy, and/or disabling stroke (endpoints). Sample size: 4,796 total patients from 11 studies.

Preventative measures Treat other risk factors: Lifestyle changes, smoking cessation, control blood pressure Patient education

References DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. 116305, Carotid artery stenosis repair; updated 2016 Jun 14, cited on 9 June 2017; Available from http://www.dynamed.com.cmich.idm.oclc.org/login.aspx?direct=true&site=DynaMed&id=116305. University of Michigan. 2000. http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/clinicalcases/endarterectomy/case.html Meier P, Knapp G, Tamhane U, Chaturvedi S, Gurm HS. Short term and intermediate term comparison of endarterectomy versus stenting for carotid artery stenosis: systematic review and meta-analysis of randomised controlled clinical trials. BMJ. 2010;340:c467. http://www.bmj.com/content/340/bmj.c467.full Legg, T. The top 10 leading causes of death in the United States. MNT; 2017. Retrieved from http://www.medicalnewstoday.com/articles/282929.php. Spangler EL, Goodney PP, Schanzer A, Stone DH, Schermerhorn ML, Powell RJ, Cronenwett JL, Nolan BW, Vascular Study Group of New England. Outcomes of carotid endarterectomy versus stenting in comparable medical risk patients. Journal of vascular surgery. 2014;60(5):1227-31. http://www.osric.com/bingo-card- generator/?title=Carotid+Artery+Stenosis&words=Revascularization%2C+Prevalence%3A+%3C10%25+of+the+population%2C+Moderate %3A+50%25-69%25%2C+Severe%3A+70%25-+99%25%2C+5%2F10+top+cause+of+death%2C+2014+meta-analysis%2C+2010+meta- analysis%2C+Patient+Education%2C+Smoking+Cessation%2C+Endarterectomy%2C+Stent%2C+High+Blood+Pressure%2C+Asymptomat ic%2C+Symptomatic%2C+Atherosclerosis%2C+Auscultation%2C+Bifurcation&freespace=false&freespaceValue=&freespaceSubheadingVa lue=Free+Space&freespaceRandom=false&width=4&height=4&number=15#results