Torsello_US_Cardiology_book_temp 27/10/2009 09:48 Page 84
Interventional Cardiology
Treatment Strategies for Patients with Acute Carotid Syndromes
Giovanni Torsello, MD and Konstantinos P Donas, MD
Department of Vascular Surgery, St Franziskus Hospital Münster, and Centre of Vascular and Endovascular Surgery, Münster University Hospital
Abstract
Carotid endarterectomy has been validated as an effective treatment option in the secondary prevention of acute carotid syndrome, i.e.
development of acute neurological events such as transient ischemic attack, or stroke, caused by carotid occlusive disease. On the other hand,
the evolution of new endovascular devices has improved the procedural safety and clinical outcomes of carotid artery stenting; however, the
utility of these techniques in this clinical entity remains controversial. The aim of this article is to present a multidisciplinary, patient-specific
treatment strategy for patients with acute carotid syndromes, reviewing the indications and limitations of surgical and catheter-based modalities.
Keywords
Acute carotid syndrome, carotid endarterectomy, carotid stent-supported angioplasty, stroke
Disclosure: The authors have no conflicts of interest to declare.
Received: July 28, 2009 Accepted: October 4, 2009
Correspondence: Giovanni Torsello, MD, Department of Vascular Surgery, St Franziskus Hospital Münster, and Centre of Vascular and Endovascular Surgery, Münster University
Hospital, Hohenzollernring 72, 48145 Münster, Germany. E: Giovanni.Torsello@SFH-MUENSTER.de
Stroke is a leading cause of death and disability in the developed of clot present, and the presence or absence of collateral vessels.
world.
1
More than 750,000 strokes occur in the US annually,
1
and Common symptoms include weakness, dizziness, blurred vision or
one-third of these patients die during the first few months after their visual loss, speech and comprehension problems, and, finally,
strokes. Acute carotid syndrome (ACS) is defined as a set of signs and cognitive impairments.
symptoms linked to neurological deficits (transient ischemic attack
[TIA] or ischemic stroke) caused by carotid occlusive disease (COD). Unstable Atherosclerotic Plaque Presentation
Atherosclerosis is a diffuse process with underlying chronic
Without surgery, the 90-day stroke risk for symptomatic extracranial inflammation that involves vascular, metabolic, and immune factors,
carotid stenosis (>50%) may be as high as 20–30%.
2,3
The timing which may lead to plaque vulnerability. There are several types of
of carotid endarterectomy (CEA) for ACS is a key benchmark for dangerous plaque believed to cause neurological symptoms. Plaque
secondary stroke prevention because delays in endarterectomy are rupture expressing tissue factor, resulting in thrombus formation,
associated with an increased risk for recurrent stroke.
4
On the other occurs when the constituents of the plaque are exuded into the
hand, the development of new endovascular technologies—the circulation.
5
A thrombus can also occur on a de-endothelialized
advent of cerebral embolic protection devices (EPDs)—has improved (ulcerated) but otherwise intact plaque
5
(see Figure 1). This may
the procedural safety and clinical outcomes of carotid artery stenting lead to hemodynamic compromise due to vessel occlusion, even
(CAS). Thus, CAS has been proposed as an alternative therapeutic without a plaque rupture.
5
Another possibility is to have thrombus on
modality for COD because it allows for shorter hospitalization the nidus of a calcified nodule that projects into the circulation and
and convalescence after treatment. This article suggests a may act as a ‘lightning rod’ for thrombus formation, embolizing
multidisciplinary, patient-specific treatment strategy for patients and causing a cerebrovascular event.
5
A final possibility is a thrombus
with ACS, reviewing the indications and limitations of surgical forming within the plaque, leading to further carotid stenosis
and endovascular techniques. and hemodynamic compromise.
Clinical Presentation Imaging
Stroke is a devastating disease associated with loss of mobility, Prospective studies with ultrasound found that an echogenic plaque
independence, and communication, leading to a huge healthcare has a lesser risk for stroke than a lipid-filled echolucent plaque.
6
Other
costs and lost productivity. Patients present with a wide variety of investigators have looked at carotid intima medial thickness (IMT) as
symptoms depending on the vascular territory involved, the amount a marker for vulnerability to future cardiovascular events.
7
Carotid IMT
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