Question of the Week # 429

429) A 72-year-old man presents for an out patient follow up after being discharged from the hospital two days ago. He was admitted for a transient ischemic attack on the right side of his body which resolved spontaneously. He was worked up and subsequently discharged. Review of his in-patient investigations reveal a carotid doppler which revealed 100% stenosis of the left carotid artery and a 40% stenosis of the right carotid artery. He smoked about 1 pack per day for past several years. His past medical history includes chronic atrial fibrillation for which he has been on Aspirin alone. During the last admission, he was started on Coumadin as well. Today, his INR is therapeutic at 2.5 . His fasting lipid profile shows a calculated LDL cholesterol of 60mg%.  On examination, there are no neurological deficits. His blood pressure is 110/70 mm Hg. In addition to recommending smoking cessation and lifestyle changes along with continuation of coumadin, which of the following is most appropriate at this time?

A) Carotid Endarterectomy of Right Carotid Artery

B) Carotid Stenting of left carotid artery

C)  Carotid Endarterectomy of Left Carotid Artery

D) Carotid Magnetic Resonance Angiography

E) No other intervention indicated

17 Responses

  1. c carotid endarterectomy is done for more than 70% stenosis

  2. No intervention is indicated

  3. E

  4. D

  5. c

  6. e

  7. C but he just control the coagulation time for prepare surgery.

  8. E

  9. c

  10. D) Carotid Magnetic Resonance Angiography -to confirm the findings from Doppler
    Carotid Endarterectomy is done only with 70 -99% stenosis (Not A B C E)

    • Very good!

      • it is a great relief to see your ENDORSEMENT !!! Thank you kindly

  11. Thank u!

  12. Does 100% Carotid Artery Stenosis Need Endarterectomy?

    For this question I posted earlier on Facebook at http://facebook.com/archereview, ” Is carotid endarterectomy indicated if there is 100% stenosis of carotod artery? ” ,
    majority of users have answered “Yes” . The purpose of this question is to clear that misconception.

    100% DOES NOT IMMEDIATELY MEAN “DANGER” . Remember all guidelines recommend carotid endarterectomy for secondary stroke prevention if stenosis is between 70% to 99% they do not say 100% stenosis. Ever wondered why?

    No intervention indicated for 100% carotid block stenosis because
    if a patient has 100% block and is still alive, he already has collaterals compensating for the supply area. A 99% block is dangerous because a thrombus can form in the non-occluded lumen and break off in that area leading to atheroembolic CVA but there is no such danger in 100% block because no free lumen is left for a new clot to form. In 100% stenosis, a network of interconnected vessels exists at the base of the brain allowing blood to flow up the cervical spine, via the opposite side carotid artery and via collateral vessels on the face communicating with the brain above the eye brows called the supraorbital arteries. Both sides of the brain can be supplied via one good vessel with open communications. Reopening an artery closed for some time can cause damage to the vessel itself which will ultimately cause it to clot off again. In addition, the procedure might also shower small particles of plaque and clot into open arterial beds causing a stroke.

    Answer : Total stenosis (100%) are left alone ( exception: in the absence of a sudden, evolving stroke where the artery has a clot and can be cleaned out quickly with a clot buster or surgery) .

    Caution : However, we should always make sure that the occlusion is 100% because carotid doppler can sometimes overestimate the occlusion depending on the observer’s experience. So, an MRA ( angiogram) must be performed to confirm 100% blockage. If it was overestimated by the other studies and if it is really in the range of 70-99% stensosis, then patient may still be a candidate for surgery.

    • great case !
      concise explanation !
      thank you kindly

  13. EEE

    • sorry i was wrong….

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