Carotid atherosclerotic disease can be treated surgically with carotid endarterectomy (CEA) or with carotid angioplasty and stenting (CAS). The evidence from randomized clinical trials comparing CEA with best medical management in both symptomatic and asymptomatic patients is substantial. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) for surgical intervention found that CEA significantly reduced the risk of further stroke (17% at 2 years) and death (7% at 2 years) for patients with stenosis at or greater than 70%.3 The Asymptomatic Carotid Artery Stenosis Trial (ACAS) found that patients with greater than 60% stenosis had a 6% reduction in risk of stroke or death at 5 years.4 Since the results of these major trials, carotid stenting has surfaced as an alternative to surgery, especially in those patients who are poor surgical candidates.
The recent results from the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)5 compared endovascular and surgical techniques in both symptomatic and asymptomatic patients and found comparable rates of the primary outcome measure of death, stroke, or myocardial infarction in the perioperative period and any ipsilateral stroke at 4 years, although perioperative stroke and myocardial infarction occurred more frequently in the stenting and CEA groups, respectively. However, the results of this trial should be interpreted with caution. The perioperative stroke but not myocardial infarction was associated with worse health status at 1 year in quality of life assessment, suggesting that the primary end point may have not been appropriately weighted to account for the greater morbidity rate associated with perioperative stroke and may have biased results in favor of stenting. Moreover, while rigorous credentialing of endovascular surgeons in this study is certainly a major strength of the design, such high standards may be possible only at highly specialized institutions. Hence, while carotid stenting is a suitable alternative in patients who are poor operative candidates, CEA remains the gold standard treatment for high-grade stenosis.
This patient has a number of cardiovascular risk factors and a possible history of angina, potentially placing her at high risk for surgery. However, carotid stenting may be difficult to accomplish safely and effectively in this patient for the following reasons. First, CTA demonstrates a significant amount of calcification at the bifurcation, which makes both the degree of stenosis and the anatomic margins difficult to evaluate. Second, the lesion of the location involves the bifurcation, which will complicate balloon positioning and inflation as well as stent deployment. Third, the proximal ICA has a tortuous appearance, which combined with the significant calcification creates a technically challenging situation for the endovascular surgeon and increases the risk of arterial trauma/dissection and thromboembolism. Hence, CEA is the best intervention for this patient, pending, of course, medical clearance by a cardiologist. She should also be continued on ASA up until surgery.6
This patient was subsequently seen by the cardiology service, who found no evidence for coronary artery disease based on history and physical examination and deemed her suitable for surgery. The patient remained on ASA 325 mg tid for 2 days and then proceeded to the operating room for CEA. The patient was placed under general anesthesia, intubated, and her neck was prepped and draped in the sterile fashion. A linear incision was made along the anterior border of the sternocleidomastoid muscle, and the usual neck dissection resulted in identification of the right common, external, and internal carotid arteries. The patient was heparinized and her blood pressure was elevated greater than 200 mm Hg. The segments of the carotid were cross-clamped, an arteriotomy was performed; the atherosclerotic plaque was identified and dissected from the intima, with copious irrigation with heparinized saline throughout the process. The arteriotomy was closed uneventfully, the arteries were unclamped, the systolic blood pressure (SBP) was lowered to 150s, and Doppler confirmed patency of the vessel. Of note, no electrocardiographic (EEG) changes were observed throughout the operation. The skin was closed, the patient was extubated and returned to the neurologic intensive care unit (NICU) for further management.