Case Study: Chapter 04

Chapter 4: Surgical and Endovascular Approach to Carotid Artery Revascularization

MARIA E. LITZENDORF, MD; MICHAEL R. GO, MD

CASE STUDY:

A 74-year-old male presents for initial outpatient evaluation after a screening carotid duplex was per- formed by his primary care provider. His medical history is significant for hypertension and diabetes. He recently underwent coronary artery bypass using the left internal mammary artery (LIMA). He does not describe focal weakness, amaurosis fugax, or prior stroke. He denies any dizziness, claudication, or paresthesias.

He has smoked one-half pack daily for the last 40 years. His father died at age 65 following an MI, and his mother died at age 83 from complications of COPD. He has one brother with coronary artery disease.

His medications include insulin and atenolol.

On physical exam his vital signs are heart rate 70, blood pressure 130/90. He is neurologically intact, with no deficits. He has soft carotid bruits bilaterally. He has 2+ bilateral pulses throughout.

The carotid duplex shows a 50% stenosis on the left internal carotid artery, and less than 50% stenosis on the right.

Case Study: Chapter 4

* 1.) What is the most appropriate initial management for this patient?
* 2.) The patient presents 3 years later, after suffering a stroke 1 week ago, where he lost the ability to move his left arm. He has no residual deficits, and the remainder of his history and physical is unchanged.

He has started taking an aspirin daily since his initial visit, and was also started on a statin. A carotid duplex shows a 60% stenosis on the right, and 80% stenosis on the left. What is the most appropriate management?

3.) You note that the patient has recently had worsening COPD, and you decide to perform a carotid angiogram. The arch aortogram is shown (Figure 4.6). Which of the following factors makes CEA more desirable than CAS for treating the carotid stenosis?