Modern treatment of patients with carotid stenosis

Abstract

Narrowing of the carotid arteries, carotid stenosis, (CS) is a frequent manifestation of atherosclerosis. It can be associated with other diseases of peripheral blood vessels, stenotic occlusive or aneurysmal, but also coronary arteries. Almost 15% of ischemic strokes are caused by this disease, which shares common risk factors with other atherosclerotic manifestations (age, male gender, hypertension, diabetes, smoking). The disease is progressive and with progression comes the progression of the degree of stenosis, the volume and morphological characteristics of the plaque. As these features progress, they increase the risk of clinical manifestations. Ischemic stroke, transient ischemic attack or transient blindness in the ipsilateral eye (amaurosis fugax) are the only clinical manifestations that can be directly related to carotid stenosis. Ischemic changes in the brain parenchyma, which can be seen on magnetic resonance imaging or computed tomography, are also associated with carotid stenosis. All the mentioned parameters are taken into account when making decisions about further treatment. Available drug therapy includes antiplatelet and statin therapy with control of risk factors (body weight correction, smoking cessation) and associated diseases (hypertension, diabetes, etc.). Invasive treatment includes carotid endarterectomy (CEA) as vascular or carotid stenting (CAS) as endovascular treatment. KEA is performed under local or general anesthesia, increasingly under local anesthesia, and after accessing the carotid arteries through a cervicotomy, they are clamped, the flow is interrupted, and after the artery is opened, plaque removal and endarterectomy are performed. In addition to the anesthesiological management of the patient and the performance of the surgical technique, the monitoring of cerebral perfusion during clamping is an important technical detail in these operations. KAS is performed through a percutaneous transfemoral approach under local anesthesia when a stent is implanted in the carotid artery at the site of the carotid stenosis. To perform this procedure, adequate access is required in terms of the quality of the femoral and iliac blood vessels, i.e. the aortic arch. KAS was introduced into practice much later, and in the last 20 years, there has been a significant improvement both in terms of performance and technology with the development of modern stents and the materials used in their installation. A special contribution to this technique was the introduction of embolization protection. KAS is a complementary method to CEA and an individual approach to the patient enables the choice of method, taking into account the advantages and disadvantages of one and the other method. When it comes to symptomatic patients, CEA certainly has a significantly greater advantage and when the use of CAS should be avoided. Complications of both methods are general, local and neurological, with the latter being the most important. Current recommendations state that performing these procedures is beneficial for the patient if the risk of neurological complications is less than 3% in asymptomatic patients, or less than 6% in symptomatic patients. At the Clinic for Vascular and Univascular Surgery of the Clinical Center of Serbia, in the last fifteen years, almost 9.000 procedures have been performed due to carotid stenosis, of which about 10% (960) were CAS. We opt for this method in patients who are at cardiorespiratory risk for CEA or in whom access to the carotid bifurcation is difficult. All, the CEA procedures are performed under conditions of the cervical block. The improvement of patient stratification and the use of artificial intelligence should in the future help doctors decide on the method of examination and treatment of these patients.