Carotid Artery Revascularization

A 64-year-old man with a past medical history of diabetes mellitus, hyperlipidemia, and hypertension presented with acute-onset left hemiparesis, hemisensory loss, and dysarthria. He was diagnosed with a right middle cerebral artery stroke and treated with systemic thrombolysis. His poststroke workup included a carotid duplex ultrasound and computed tomographic angiogram of the carotid arteries (Figure 1), which confirmed a severe (70%–99%) stenosis in the right internal carotid artery (ICA) secondary to a 20-mm-long atherosclerotic plaque extending from the carotid bifurcation to the level of C2-C3 disc space. The left ICA showed moderate (50%–69%) stenosis. Should this patient be recommended for carotid artery revascularization, and, if so, by which method?Figure 1. Computed tomographic angiogram of the 64-year-old patient presented in this case, showing severe right internal carotid artery stenosis (arrow) in coronal ( A ) and sagittal ( B ) views.Stroke, defined as acute development of a focal neurological deficit attributable to the disruption of blood flow to the brain, is caused by 1 of 2 main causes: ischemia or hemorrhage. The majority (>80%) of strokes are of ischemic etiology, of which ≈15% to 20% are attributable to atherosclerosis of the extracranial carotid arteries. The risk of death and recurrent stroke increases following an ischemic stroke. Transient ischemic attacks, or strokelike symptoms that last <24 hours, are also associated with an increased risk of early recurrent stroke, particularly in patients with carotid artery atherosclerosis.The bifurcation point of the common carotid artery, or carotid bulb, is predisposed to the development of atherosclerosis owing to low wall shear stress and resulting flow stagnation. Narrowing or stenosis of the carotid bulb and ICA because of atherosclerosis can lead to ischemic stroke secondary to plaque embolization or hypoperfusion. The prevalence of ICA stenosis is estimated to be 2% to 3% in the general population, with increased prevalence noted …