Management of Carotid Artery Stenosis - Essay Example

Management of Carotid Artery Stenosis/ CEA CAS/CEA. A Literature Review There are presently many clinical trials as well as random studies being done, based on the fact that carotid artery stenoses cause stroke and debilitation of large numbers of people in the United States every year. The standard of care for carotid artery stenosis over the last few years has been CEA but there are other treatments being used and trialed. This l1terature review will briefly describe what there is in the way of literature to support treatment and CEA. Carotid atherosclerosis most often affects the carotid bifurcation and the proximal internal carotid artery. Progression of plaque at the carotid bifurcation results in luminal narrowing, sometime accompanied by ulceration. The result can be ischemic stroke or transient ischemic attack. These occur because of hemodynamic compromise, embolization, or thrombosis (Greelish, Mohler, Fairman, 2009). The review by Greelish, (2009), includes major trails which evaluate the efficiency as well as clinical variables and risk. There are two major trials discussed in this paper, those are the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial. Each of these demonstrate the efficacy of the carotid endarterectomy in patients who have symptoms such as transcient ischemic attack (Greenlish, et.al, 2009). The NASCET cohort is another study done that suggests the benefits of CEA in symptomatic patients may be overestimated, since a number of strokes that occur in the territory of stenotic arteries are not preventable by CEA. 1800 patients were included in this study which was done to assure that we knew what the true risk factors of this group of patients with stroke might be. This study showed that that stroke occurred most often in people that had 60% stenosis. This is well supported in all of the studies that were reviewed. Patients with 60% occlusion whether symptomatic or asymptomatic are at great risk. Risk factors lead to damage in the carotid arteries and therefore contribute to the progression of atherosclerotic cerebrovascular disease and reduction of those risk factors are important in reducing the occurrence of ischemic stroke. Secondary prevention of stroke: risk factor reduction by Furie, Wilterdink and Kistler, (2009) review risk factor management of patients with atherosclerotic cerebrovascular disease, with a focus on secondary prevention in patients who have had ischemic attack or ischemic stroke. Those risk factors that are discussed in great depth in this paper are hypertension, smoking, diabetes, metabolic syndrome, and dyslipidemia. They show statistical data on those patients that control these risk factors and those that don't as well as how the CEA fits into this care (Furie, et. al., 2009). CEA alone will not forever cure a patient with large number of risk factors. The patient has to be willing to participate in this care, also. Cardiovascular disease, MI or ischemic stroke is still the leading cause of death in patients with metabolic syndrome and diabetes. Haffey, (2009), suggests success in saving lives here is based on effectively treating the whole patient. The author describes throughout his paper, different clinical approaches to achieving this goal. He reminds that treating those things that are risk factors for the disease should be dealt with aggressively. Those include hypertension, smoking, activity levels, dietary habits, obesity, carotid artery stenosis, and atrial fibrillation (Haggey, 2009). Again, as in the previous literature, Dr. Haggey suggests that there be a great deal of follow up assuring that these patients are doing what has to be done to decrease their risk factors. There have been three very high quality clinical trials on patients who need carotid endarterectomy but are asymptomatic. Those trials are the Veterans Affairs Cooperative Study Group, the Asymptomatic Carotid Atherosclerosis Study, and the Asymptomatic Carotid Surgery Trial. The trials are discussed at length by Greelish, Mohler, and Fairman (2009) in their review for physicians entitled Carotid endarterectomy in asymptomatic patients. The VA study presented the first evidence available on the use of CEA in asymptomatic patients with carotid stenosis. It was a multi-center random study. The ACAS trial, on the other hand, was a very large randomized trial showing asymptomatic patients who eventually had TIA and results of CEA in this group and the last study though done in a randomized manner was determined by Greelish, et. al. (2009) to not be conducted well enough to be of statistical use. CT angiography is one of the initial levels of care or diagnosis still used at this time. Another frequent method used is carotid dopplar. These procedures are quite accurate in helping us with a diagnosis of carotid artery stenosis or occlusion. The amount of occlusion seen during exam can determine how fast a patient may need to go to surgery. Although most CEA's are scheduled there are a few done on emergent basis, especially since quick reaction to several diagnosis is being required by Medicare and some insurances. (Josephson, Bryant, Johnson, 2004). This article discusses the different types of testing available and what that testing means in the sense of which treatment might be the best used. Bruce Mintz and Robert Hobson (2000) are more in-depth in their descriptions of management and treatment of patients who have carotid arterial occlusive disease and the comorbid illnesses that ensue. There has been some extensive debate over the last few years about how this treatment should be organized for best outcome. Ultrasound technology has allowed the ability to objectively find the severity of any carotid stenosis in those regions that we know are commonly accountable for stroke. Randomized trial such as those mentioned earlier improve our understanding of this disease and the need for aggressive therapy, including that of CEA (Mintz, et.al., 2000). It has been found that carotid endarderectomy coupled with optimal medical management is better than using medical management alone in patients that have 70% or greater stenosis and are asymptomatic (Mintz, et.al, 2000). According to Waters and Stanley (1992), the obstructing thrombus that may very well be in the stump could shower cerebral emboli. Surgical treatment may prevent this from happening and abate the symptoms at the same time (Water, et.al., 1997). The general population is aging and the availability of noninvasive is improving which allows the diagnosis of carotid artery stenosis to be diagnosed more often. Rabinstein and Brown (2009) differentiate between various types of treatment for carotid artery stenosis. Antiplatelet therapy and aggressive treatment of vascular risk factors are felt to be the mainstay of treatment. Class I evidence however shows that CEA if very effective in preventing ipsilateral ischemia but they feel that the benefits are marginal. This article has balance in determining the best levels of care for the patient. Rabinstein states that there are several clinical trials coming up over the next couple of years to determine medical versus surgical treatment of these cases (Rabinstein, L., Brown, R. (2009) The causes of stroke in patients with asymptomatic carotid-artery and asymptomatic carotid stenosis have not been carefully studied according to Inzitari, Eliaszie, & Gates, et.al (2000). This paper discusses the fact that the authors believe that there are not enough studies done to determine that CEA is the best treatment for a patient. The study they conducted contained patients that had asymptomatic contra lateral stenosis. They looked closely at the severity, risk and predictors of stroke that this group of patients had. They concluded their study stating that he risk of stroke among patients that are asymptomatic is fairly low. 45% of strokes, according to these authors, in patients that have asymptomatic stenosis of 60-90% are caused by lacunes or cardioembolism. They, in other words, feel that the benefit of CEA is overestimated (Inzitari, et.al., 2000). Stroke is the third leading cause of death worldwide according to Warlow and Gijn (2008). It accounts for 105 to 12% of the deaths in industrialized companies. It is found recently however, that about 2/3 of the patients comes from nonindustrialized countries. Stroke is a debilitating disease in that often even after rehabilitation, patients need help carrying out everyday activities. The rest of the family is definitely impacted. Therefore there are millions of people worldwide that affected in some way by stroke. The earliest diagnosis and treatment available is recommended tin an attempt to decrease this impact (Warlow, Gijn, Dennis, 2008). Stroke is the leading cause of disability in the United States. Stroke costs the national economy approximately 40,000 billion dollars in direct and indirect care costs. About one quarter of these events will be caused by occlusive disease of the cervical internal carotid artery. With few exceptions, the North American Symptomatic Carotid Endarterectomy Trial (NASCET), European Carotid Surgery Trialists Collaborative Group (ECST) and Asymptomatic Carotid Acarcaderais Stude (ACAS) have shown that CEA substantially reduces the risk of stroke (Hanel, Xavier, Kirmani, et.al., 2003). This article is featured in The New England Journal of as a case study of the TIA patient. Common clinical problems with this case are discussed as well as evidence supporting various strategies. Transient ischemic attacks have an annual incidence of 200,000 to 500,000 in the United States. This article is not very in-depth for any of the issues or outcomes that are covered and would probably not be helpful in formulation of a new study or paper (Johnston, 2002). Carotid endarterectomy (CEA) has been used for the past several decades of care for this group of patients. It has been documented through many randomized control trials that this procedure is highly effective Those patients who are symptomatic get more benefit than those that are not according to the trials (Brott, Brown, Miller et.al. 2004). However, it is also noted that asymptomatic patients with stenosis 60% or greater are less likely to have a cerebral stroke than those that are symptomatic. Recently carotid artery stenting has become popular for patients with occlusive disease. As this procedure continues to be used more often, the outcomes begin to approach those of the CEA (Brott, et.al, 2004). Meschia, Brott, & Hobson, (2007) agree in their article of diagnosis and treatment. The discussion here centers on detecting stenosis and creating a revascularization as soon as it is possible. It is determined in their articles that surgery is an acceptable risk in patients who have 70% or more occlusion and they recommend CEA for patients with 50% or more occlusion. They feel there are mixed results lower than that and there are also mixed results related to the use of stints (Meschia et.al., 2007). On the other side of the argument, Abbott, (2010) states that the one best treatment for carotid artery disease is medical. She states that there have been significant numbers of studies done and each of those has shown different things. The most significant data, however has come from the fact that if a patient is treated early in their disease process, surgical intervention is not necessary. Her literature review showed that medical intervention improved symptomology by 50% when caught early and decreased the cost by 3-8 times (Abbott, 2010). Hegland, Kurz, Munk and Larsen (2010) have published a study that shows that the progression of carotid artery disease is decreased in the patient who is placed on statins. The study was meant to examine the effect of early statin treatment on progression of internal carotid arteries and compare patients that were placed on statins with those not placed on statin. Repeated dopplar exams were done to follow the patients. The results showed that 19% of ICA stenosis slowed with statin therapy while 74% showed a regression of the stenosis. 68% of patients not on states showed progression of the disease. This would seem to suggest that starting patients on statins may not only stop the progression of their disease but make it better (Hegland, et.a. 2010). Solomon and Klein (2008) discuss alternatives of care more than they do the CEA. Medications such as hydrochlorothiazide (25 daily), simvastatin (20 mg daily), and aspirin (81mg daily), are addressed in great depth as standard of practice. Risk factor such as smoking and alcohol are also discussed at great depth including the effects on the patient even post treatment. Their recommendation includes assuring that there risk factors are abated in the patients that has time before surgery. Body mass index is also of grave consideration. Again, Solomon et.al. (2007) suggests where there is time that the patients BMI be decreased where applicable. A full cardiac workup including blood pressure and heart rate will need to be done according to Solomon but not everyone agrees that a complete workup prior to this surgery is needed. (Solomon, et.al., 2007). Extracranial Carotid Stenosis by Sacco (2001) begins with a case study which highlights the commons of this clinical problem. Evidence is then presented to support various clinical strategies of care. A review of formal guidelines takes place throughout the article. He thoroughly reviews recommendation for clinical care of these patients. There is also evidence presented from several studies that have been done with outcome data. Suggested formal guidelines for use gives this articles merit in use as part of the groundwork for further study. Previously we have discussed the stenting might be an alternative to CEA. In this study, the authors, Gurm, Yadav, Fayad et.al. (2008), studied the long term results of carotid stinging versus endarderectomy in high risk patients. The method used was a randomized trial using three hundred and thirty four patients. They only looked at patients that had at least a 50% stenosis of the luminal diameter or an asymptomatic stenosis of 80% They studied these patients for three years, some with CEA and some with stints. The final outcome was that there was no significant difference for either group of patients after three years (Gurm, et.al, 2008) Arguments in the best outcomes for the use of stenting versus endarterectomy in patients with symptoms rages on. Carotid stinting is less invasive than endarterectomy but the safety for use in patients who are symptomatic is still unclear. The authors of this study conducted a multicenter, randomized, noninferioity trial comparing stenting to endarderectomy in patients that were symptomatic and had a stenosis that was greater than 60%. In this case, the trail was stopped prematurely because of safety issues as well as issues of futility in the study. The incidence of stroke or death after CEA at the time it was stopped was 3% and it was 9.6% for stenting. The outcome assumption here was that CEA was safer than stenting in patients with 60% occlusion (Mas, Chatellier, Beyssen, et.al, 2006). CEA continues to be the gold standard of care for the patient with carotid stenosis. However, as we have shown in our literature review stenting is making an attempt at becoming as good therapeutically as the CEA. Many more studies will have to be done to show that the results are as good. In fact, many of the recent studies show that the results are not as good, in fact have a higher death and stroke rate. There have been a total of 12 recent randomized trials, none of which could show superiority of the CAS (Zeebregts, Meerwaldt, & Geelkerken, 2009). These authors believe that stenting should be reserved for high risk surgical patients or those that have anatomical restrictions Bibliography Abbott, A. (2010). Medical intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a system. Stroke. 40(10). 573-583. Brott, TG, Brown, RD, Miller, DA, Meyer, FB, Cloft, JH, & Sullivan TM. (2004). Carotid revascularization for prevention of stroke: carotid endarterectomy and carotid artery stenting. Mayo Clinic Proceedings 79(9) 1197-208. Retrieved Jan 11, 2010 from URL: www.cinahl.com/cgi-bin/refsvcjid Furie, K., Wilterdink, J., & Kistler, P. Secondary prevention of stroke: Risk factor reduction. UpTo Date. http://www.uptodateonline.com/online/content/topic.dotopicKey=cva_dise/5131&view=p... Greelish, J., MD, Mohler, E., MD, Fairman, R., MD. (2009). Carotid endarterectomy in asymptomatic patients. UpToDate. http://www.uptodateonline.com/online/content/topic.dotopicKey=vascular/17899&view=... Greelish, J. MD, Mohler E. MD, & Fairman, R. MD. Carotid endarterectomy in symptomatic patients. UpToDate. http://www.uptodateonline.com/online/content/topic.dotopicKey=vascular/18927&view Gurm, H., Yadav, J., Fayad, P., et.al. (2008). Long term results of carotid stenting versus endarterectomy in high risk-patients. The New England Journal of Medicine. 358(15). Retrieved Dec. 11, 2010 from http://content.nejm.org/cgi/content Haffey, T. (2000). How to avoid a heart Attack: Putting it all together. JAOA. 109(5). 14-20. Retrieved Jan. 11, 2010 from http://www.jaoa.org/cgi/content/abstract/109/5_suppl_1/S14maxtoshow=&HITS=10&hit Hanel, R., Xavier, A., Kirmani, J., Yahia, A., Qureshi, A. (2003). Management of carotid artery stenosis: comparing endarterectomy and stenting. SpringerLink-Journal Article. Hegland, P., Kurz,M., Munh, P. The effect of statin therapy on the progression of carotid artery stenosis in relation to stenosis severity (2010. Acta Neurologica 12(1). 11-15. Inzitari, D., Eliasziw, M., Gates, P. (2000). The causes and risk of stroke in patients with asymptomatic internal-carotid-artery-stenosis. The New England Journal of Medicine. 342(23). Retrieved from http://content.nejm.org/cgi/content/ Johnston, C. (2002). Transient ischemic attack. The New England Journal of Medicine. 347(21). 1687-1692. 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The New England Journal of Medicine. 345(15). 1113-1118. Retrieved from http://content.nejm.org/cgi/content Soloman, C., Klein, A., Hamel, M. (2008). Management of Carotid Stenosis. 358(150. 1617-1621. The New England Journal of Medicine. Retrieved Jan. 11, 2010 from http://content.nejm.org/cgi/content/short Warlow, C., Gijn, J., Dennis, M. (2008). Stroke:practical management. The New England Journal of Medicine. 359(11). 1188-1189. Retrieved Jan 11, 2010 from http://content.nejm.org/cgi/content Wateres, DJ., & Stanley, WE. (1997). Cerebral emboli from the stump of a totally occluded carotid artery: surgical management. JAOA. 92(8). 1052-1053. Retrieved from http://www.jaoa.org/cgi/content/abstract/92/8/1952mastoshow=&HITS=10&hits Zeebregts, CJ, Meerwaldt, R, Geelkerken. (2009). Carotid artery stenting: a 2009 update. Current Opinion in Cardiology. 24(6), 528-31. Retrieved Jan 11, 2010 from http://web.ebscohost.com/ehost Read More