Surgery for carotid artery stenosis

Editor—While shopping in Florida, a man found a booth offering carotid duplex scans for a modest fee. He had a family history of cerebrovascular disease, so he decided to be scanned for peace of mind. Unfortunately, a critical internal carotid stenosis was found.

He returned to his hotel somewhat perturbed, only to be phoned by a vascular surgeon recommending urgent carotid endarterectomy before he flew home to the United Kingdom. He declined the offer, but underwent successful surgery some months later.

Screening is not without drawbacks. The asymptomatic carotid surgery trial confirms that carefully selected patients benefit from surgery when operated upon by skilled teams.¹ The logic, which Toole finds compelling,² is that carotid screening should be considered.

Figure 1.

Credit: CNRI/SPL

Transcranial Doppler ultrasound can detect microemboli, which allows the efficacy of therapeutic interventions to be rapidly and non-invasively assessed. Controlling the rate of embolisation reduces the risk of an early postoperative stroke.³ Controlling emboli and symptoms in patients with recurrent or crescendo transient ischaemic attacks by using Doppler directed drug therapy allows these high risk patients to undergo elective carotid surgery safely.⁴

Patients with focal neurological events need assessment within 24-48 hours. Those with critical carotid stenoses, symptoms and emboli should be admitted to a stroke prevention unit (similar to a coronary care unit). It would be jointly managed by vascular surgeons and stroke doctors, with high ratio of staff to patients. Rapid control of microemboli could be achieved, and since microemboli seem to be surrogate markers for future embolic events, some strokes will be prevented.