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Chapter 95: Carotid Artery Stenting

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Which of the following is incorrect regarding asymptomatic carotid stenosis?

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A. The severity of the carotid bruit correlates with the severity of the stenosis

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B. Patients are likely to have collaterals to the affected hemisphere

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C. Stroke risk in these patients is mainly from embolism plaque

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D. Revascularization can be considered for patients with > 80% asymptomatic stenosis

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E. None of the above are incorrect

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The answer is A. (Hurst’s The Heart, 14th Edition, Chap. 95) The detection of a carotid bruit during a clinical exam often leads to the diagnosis of asymptomatic carotid stenosis. However, neither the presence nor the severity of the bruit correlates with the severity of the stenosis (option A). The absence of symptoms in patients with severe, hemodynamically significant stenosis signals the presence of robust collaterals to the culprit hemisphere (option B) — most often from the contralateral carotid artery via a patent anterior communicating artery or from the VB circulation via a posterior communicating artery. The stroke risk in these patients is mainly from embolization from the stenotic plaque in the extracranial ICA to the intracranial vessel(s) rather than from complete occlusion of the carotid artery in the neck (option C). Per current guidelines, it is reasonable to consider revascularization for patients with > 80% asymptomatic stenosis and low periprocedural risk (option D).1

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During a routine physical examination, a carotid bruit is auscultated in a 46-year-old obese man. The results from a duplex ultrasound and angiography confirm asymptomatic carotid stenosis. Regarding treatment options, which of the following arguments in favor of interventional therapy is incorrect?

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A. Statin therapy is not effective in decreasing the total number of fatal strokes

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B. Compliance with medical treatment may be diminished due to the lack of symptoms

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C. Response to medical treatment of an established stroke is unpredictable

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D. Revascularization subjects the patient to small risks that are spread out over time

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E. All of the above are incorrect

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The answer is D. (Hurst’s The Heart, 14th Edition, Chap. 95) Proponents of medical treatment for asymptomatic disease argue that revascularization treatment for asymptomatic carotid stenosis subjects the patient to periprocedural risks that are immediate as opposed to the small risks with medical therapy that are spread out over time (option D).2 On the other hand, there are important considerations supporting the case for an interventional approach in asymptomatic patients. Because the first presentation in ...

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