Catálogo de publicaciones - libros

Carotid artery stenosis is a prevalent disease, caused predominantly by atherosclerosis. The reported prevalence is dependent on the population screened, investigative tool used, and the criteria employed. The presence of carotid artery stenosis is associated with an increased risk of stroke and other ischemic manifestations of systemic atherosclerosis (e.g., myocardial infarctions and vascular deaths). Thus, carotid revascularization strategies for stroke prevention had been aggressively pursued over the past five decades. This chapter reviews the epidemiology and prevalence of carotid artery stenosis.

Patients with carotid atherosclerotic disease are at an increased risk for stroke. This chapter reviews the risk factors associated with carotid artery stenosis and the medical interventions that decrease the cardiovascular risk from carotid atherosclerotic disease.

Internal carotid artery stenosis is responsible for approx 30% of ischemic strokes. Since the beginning of the 20th century, various surgical procedures were used for the prevention of stroke. The first successful case of carotid endarterectomy (CEA) was reported by DeBakey in 1953. Since then, CEA has been continually refined and is now the gold standard procedure to prevent largeartery stroke. In this chapter we describe the procedure, and discuss the benefits and risks of CEA as compared with medical treatment.

The goal of treatment of carotid artery stenosis is to prevent stroke and death. Stroke is the third leading cause of death in the United States. This chapter focuses on the evidence supporting the use of carotid artery stenting for treatment of carotid artery stenosis. The data supporting carotid angioplasty and stenting have been primarily observational registries and a few randomized controlled trials comparing carotid angioplasty and stenting to carotid endarterectomy. No trial has compared carotid angioplasty and stenting to medical therapy.

Defining and understanding cerebrovascular anatomy is the cornerstone of a safe and successful carotid stenting procedure. A thorough pre-procedural angiogram with detailed documentation of cerebral anatomy and collateral flow is essential for procedural success. This chapter details supra-aortic anatomy, including the aortic arch, subclavian arteries, common and internal carotid arteries, vertebral arteries, and intracranial vessels. In each section, commonly found anatomic variations are discussed. The chapter has been divided into three main sections, the great vessels, the anterior circulation, and the posterior circulation.

Noninvasive carotid artery evaluation is an essential tool to assess patients who are at risk of atherosclerotic carotid artery disease because digital subtraction angiography is invasive and carries a 0.3-1% risk of periprocedural transient ischemic attack or stroke. Currently, duplex ultrasound, computed tomography angiography, magnetic resonance angiography, and transcranial Doppler are available to noninvasively evaluate the severity of carotid artery disease. The relative merits and limitations of each technique are reviewed in this chapter. Key Words: Computed tomography angiography, duplex ultrasound, magnetic resonance angiography, transcranial doppler.

Digital subtraction angiography remains the gold standard to assess both the severity and the characteristics of cerebrovascular stenoses. A full four-vessel cerebral angiography allows accurate evaluation of both extracranial and intracranial, carotid, and vertebral arteries. A comprehensive carotid diagnostic angiography is necessary as part of the carotid artery stenting procedure to provide anatomic details for strategizing the interventional approach and for anticipating potential challenges.

Indications for carotid artery stenting (CAS) have continued to evolve since carotid artery balloon angioplasty was first introduced in the early 1980s. Indeed, with the ongoing development of endovascular techniques and hardware (including stent design, emboli protection devices, and delivery systems) designed to reduce the risks of CAS, coupled with emerging data demonstrating the long-term safety and durability of CAS; accepted indications for CAS hold promise to emerge as a standard alternative to traditional carotid endarterectomy across a wider array of patient populations.

Carotid artery stenting is a high-risk procedure that requires meticulous techniques to avoid potentially devastating complications. Performance of this procedure should be limited to experienced endovascular specialist with good catheter-based techniques. This chapter guides readers through a step-by-step approach to carotid stenting.

Since the first carotid angioplasty performed in 1980, the equipment available has evolved dramatically. This chapter reviews the modern equipment available for carotid angiography and stenting.