Vignette - TIA

[adagio]

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Patient with a story of TIA + multiple episodes of transient visual loss + with carotid angiography we find 40% stenosis in left carotid & 50% stenosis in right carotid, what is the next step?

1- Endarterectomy of left carotid
2- Endarterectomy of right carotid
3- No endarterectomy, And give aspirin for prophylaxis
4- No endarterectomy, And give hepartin for prohpylaxis

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what would you choose?

 

[Fuzuli]

The optimal management of patients with 50-70% stenosis is controversial. Some recommend performing carotid endarterectomy if there are high risk factors like being male and >75 age.

In this patient, aspirin + ER dipyridamole + drugs to modify other risk factors (anti-hypertensives, anti-diabetics, statins) is the optimal medical treatment.

 

[zenna]

Isn't the symptom warning for more than pharmacological intervention. But the occlusion is only 50%?????????

 

[adagio]

I have the same inquiry as Zenna, shouldnt endarterectomy be done because of the recurrent TIA and visual loss?

 

[Fuzuli]

No, not all symptomatic patients should undergo endarterectomy.

For symptomatic patients:

• >70% stenosis: Perform endarterectomy
• 50-70%: Controversial, endarterectomy may be done for selected patients
• <50%: Medical treatment alone

Endarterectomy should be done in selected centers with low perioperative complications rates. For patients who are not eligible for endarterectomy (like those who had previous endarterectomy), carotid angioplasty with stenting may be an alternative (again, controversial at this point).

For asymptomatic patients:

• Less data compared with symptomatic patients
• In male patients with >60% stenosis, endarterectomy may be performed
• For others: Medical treatment alone

Ultimately, the only certain indication for endarterectomy is for symptomatic patients with >70% stenosis.

 

[adagio]

I would correct your last sentence (from what I understood) so it becomes:
the only certain indication for endarterectomy is for (ANY) patient with >70% stenosis.

 

[Fuzuli]

I would correct your last sentence (from what I understood) so it becomes:
the only certain indication for endarterectomy is for (ANY) patient with >70% stenosis.

Nope, this is incorrect.

Kaplan Internal Medicine Lecture Notes 2008-2009

"Carotid endarterectomy is recommended when an occlusion exceeds 70 percent of the arterial lumen and the lesion symptomatic."

Harrisons's, 17th edition

"SURGICAL THERAPY - Symptomatic carotid stenosis was studied in the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST). Both showed a substantial benefit, for surgery in patients with a stenosis of &#8805;70%."

Cecil, 23th edition

"Carotid endarterectomy reduces the cumulative risk for any ipsilateral stroke at 2 years from 26 to 9% in patients with a 70 to 99% symptomatic (i.e., previous TIA or nondisabling stroke) internal carotid stenosis...Patients with less than a 50% symptomatic stenosis do better with medical management alone."

 

[adagio]

clarification was in order. I stand corrected.

 

[sheehan]

from Sabiston surgery-
Generally accepted criteria based on these studies are (1) for symptomatic carotid arteries, more than 50% diameter reduction; and (2) for asymptomatic carotid arteries, more than 80% diameter reduction. Although ACAS recommended surgery for patients with more than 60% stenosis, many clinicians believe the benefit of surgery or angioplasty is not achieved for asymptomatic stenoses less than 80% because of the lower risk for stroke with lesser degrees of carotid stenosis and the relative risk of these interventions.

 

[Fuzuli]

from Sabiston surgery-
Generally accepted criteria based on these studies are (1) for symptomatic carotid arteries, more than 50% diameter reduction...

This is still controversial. Although surgery texts state the indications similar to what you've written above (one may think that surgeons are biased towards CEA 🙂), medical textbooks are more conservative and have a clear indication only for those with >70% stenosis and recommend CEA for only selective patients in 50-70% stenosis.

Since this is still a controversial issue, I very much doubt if there will be a question about choosing between conservative and surgical approaches in a symptomatic patient with 50-70% stenosis.

 

[adagio]

I think this question can be easily found on actual test.

 

[slowlybutshelly]

If it was on the actual test, I would choose #3.