Carotid Endarterectomy for Secondary Stroke Prevention

In this episode of PodMD, Vascular & Endovascular Surgeon Dr Celina Kaiser will be discussing the topic of a carotid endarterectomy for secondary stroke prevention, inlcuding what a carotid endarterectomy is, how it aids in preventing a secondary stroke, when a GP should refer and more.

  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMd studio Dr Celina Kaiser, who is a Vascular Surgeon

    She is skilled in classical open vascular surgery and minimally invasive endovascular techniques.

    Today, we’ll be discussing the topic of Carotid Endarterectomy for Secondary Stroke Prevention.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Celina, thanks for talking with us on Pod MD today.

    Celina: Thank you for having me.

    Question 1
    The topic of today’s discussion is on Carotid Endarterectomy for Secondary Stroke Prevention. Celina, can you describe for our listeners what a Carotid Endarterectomy is?

    Celina: A carotid endarterectomy is a surgical procedure that aims to clear the plaque burden that develops in the carotid artery at its bifurcation, particularly affecting the blood flow into the internal carotid artery in the brain. During this procedure, the common carotid artery and these branches, the external and the internal carotid arteries are disected and isolated. The patient is systemic The Hebronites and clamps are placed on these three vessels. The arteries then open of the origin of the internal carotid artery and plug is meticulously removed from the artery. The artery is then repaired in the ed before the clamps are released and blood flow to the brain is reestablished.

    Question 2
    How would that help in preventing a secondary stroke?

    Celina: i’ll break up this answer in parts. The first part is that there are different types of strokes, hemorrhagic and ischemic, and there are different subgroups of ischemic strokes. Amongst these, there has strokes caused from large artery atherosclerotic disease, extracranial or into cranially. There are strokes caused from embolism, from a cardiac source and then strokes caused by small vessel disease. And there’s also strokes caused by other causes other than atherosclerosis or embolism, such as the section hypercoagulable states or sickle cell anemia. There is also a subgroup of patients that suffer strokes from an undetermined cause. Carotid Endarterectomy has a role in preventing strokes in the first subgroup of patients. Those with extracranial large artery atherosclerotic disease. Arteriosclerotic plaques in the carotid circulation, usually form at the origin of the common carotid artery, as it arises from the aortic arch, either by furcation of the common carotid artery in the neck or intercranial early in the siphoned portion of the internal carotid artery.

    Most clinically significant corroted plaques are localized in the carotid bifurcation making surgical treatment by endarterectomy possible. Carotid plaques that become clinically significant because they cause stonosis, occlusion or embolization are characterized by intimal cellular proliferation, lipid accumulation, calcification, hemorrhage, and necrosis. Breakdown of the endothelial cell surface. And the fiber scab exposes the underlying intima and then a chronic core to the bloodstream. This can result in platelet deposition, thrombosis and embolization of these material to the brain causing a stroke. The mechanisms that underlie progression of atherosclerotic carotid plaque to critical stenosis or to surface disruption, ulceration and embolisation are poorly understood. Interplaque hemorrhage and plaque dissection have been implicated in the development of cerebrovascular symptoms and alteration and hemorrhage are prominent features of symptomatic carotid plaques. Carotid Endarterectomy has been shown to decrease the long-term risk of stroke compared to medical therapy alone.

    Question 3
    How does someone qualify for a Carotid Endarterectomy for Secondary Stroke Prevention?

    Celina: The decision to offer surgery is patient centered and individualized. patients are selected taking into consideration their symptoms, clinical signs, imaging features, medical management, and other co-morbidities and surgical feasibility, their persistent symptoms such as amaurosis fugax ipsilateral to the carotid in question speech disturbance or face arm or leg weakness or paralysis control lateral to the effected carotid. The time of onset of the symptoms is also very relevant as there is evidence that supports carotid endarterectomy in the acute period within two weeks of the onset of symptoms to maximize the benefit of Carotid Endarterectomy in preventing secondary strokes, the risk of having a secondary stroke after the first event is highest in the two weeks that follow the event, the first event, and if untreated can remain high for as long as six months after patients that display clinical signs of recovery after the primary stroke are candidates for CEA or Carotid Endarterectomy with regards to imaging symptomatic patients with a carotid ultrasound suggesting synosis greater than 50% are generally considered for intervention. And in terms of surgical feasibility, the anatomy of the lesion, the accessibility, the patient’s overall health, all play a role in selecting patients for therapy.

    Question 4
    Is there anyone that wouldn’t qualify?

    Celina: Yes. Patients with severe strokes with significant disability may not be candidates for revascularization in the acute period. Usually these patients are given a period of time, typically six weeks in which they’re treated medically. They undergo rehabilitation and allow some time for functional recovery after which they’re reassessed for intervention. Also, patients that have had prior neck surgery, Neck radiation, and controlled lateral vocal core palsy, or a lesion that is surgically inaccessible are considered for other procedures, such as the carotid stent. And patients with Limited life expectancy due to other comordities are treated with medical management.

    Question 5
    Is there anything else you can do to avoid a secondary stroke?

    Celina: Yes. Modification of risk factors, specifically addressing cardiovascular health, commencing anti-platelet therapy, treating hypertension, treating hyperlipidemia with Statens, ceasing cigarette smoking, aiming for optimal control of diabetes and encouraging physical activity and maintaining a healthy weight.

    Question 6
    How can GPs aid in investigating whether a patient should be getting a Carotid Endarterectomy for Secondary Stroke Prevention? Or is there a way they can support a patient through it?

    Celina: Firstly, having a high index of suspicion to detect, these patients, when they present to the consultation symptoms, such as amaurosis fugax difficulty speaking, weakness or paralysis in the face arm or leg should prompt urgent investigation and referral if suspecting a stroke or Tia from the history and clinical exam, then organizing a CT brain and a CTA circle of Willis and a carotid duplex are all indicated. And based on these results, commencing medications such as anti-platelet in commencing or increasing, the dose of statens are also considerations in the patient that presents to the consultation with symptomatic carotid artery disease.

    Question 7
    When should a GP refer?

    Celina: The best outcomes for patients are achieved when their referrals are timely, a phone call to a specialist or an urgent referral to the emergency department to be further investigated on the same day is appropriate.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on Carotid Endarterectomy for Secondary Stroke Prevention?

    My three key messages would be
    1. First. take, every opportunity during consultation to address risk factors
    2. Have a high clinical index of suspicion, specifically looking for amaurosis fugax difficulty speaking, weakness or paralysis in the face, arm or leg and
    3. Refer early for imaging and specialist opinion. If you suspect you’re seeing a patient with symptomatic carotid stenosis,

    Thanks for your time and the insights you’ve provided.

    Celina: Thank you for having me

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.