Skip to main content Accessibility help
  • Print publication year: 2007
  • Online publication date: December 2014

Carotid artery disease and treatment

from Medical topics


Thrombo-embolism and haemodynamic ischaemia secondary to atheromatous stenotic disease of the carotid and vertebral arteries are important causes of ischaemic stroke. In those patients with carotid stenosis the risk of stroke has been directly related to the severity of stenosis and the presence of symptoms (Inzitari et al., 2000). The average risk of stroke following a transient ischaemic attack (TIA) is about 8% in the first year and then 5% per annum, but, in patients with severe carotid stenosis, the risk even with medical treatment increases up to 28% over 2 years (NASCETC, 1991). Detection of significant carotid or vertebral artery stenosis after a TIA or stroke provides the opportunity for secondary preventive treatment of the stenosis to prevent a further stroke (see also ‘Stroke’).

Carotid endarterectomy (CEA), the surgical removal of the atheromatous plaque, was first performed fifty years ago and is, at present, still considered the gold standard in the treatment of severe symptomatic disease (Grace, 2004). The procedure usually involves the insertion of a silicon tube (shunt) directly into the opened internal and common carotid arteries. Blood then flows through the shunt from the carotid artery to the brain allowing the removal of the atherosclerotic plaque from the artery wall. A number of randomized clinical trials on selected groups of symptomatic and asymptomatic patients have indicated the benefits of CEA (NASCET, 1991; ACAS, 1995; ECST, 1998).

Aackerstaff, R. G., Jansen, C. & Moll, F. L. (1996). Carotid enderterectomy and intraoperative emboli detection: correlation of clinical, transcranial Doppler, and magnetic resonance findings. Echocardiography, 13, 543–50.
Auperin, A., Berr, C., Bonithon-Kopp, al. (1996). Ultrasonographic assessment of carotid wall characteristics and cognitive functions in a community sample of 59–71-year-olds: the EVA Study Group. Stroke, 27, 1290–5.
Alhaddad, I. A. (2004). Carotid artery surgery vs stent: a cardiovascular perspective. Catheterization and Cardiovascular Interventions, 63, 377–84.
Bakker, F. C., Klijn, C. J. M., Grond, J., Kappelle, L. J. & Jennekens-Schinkel, A. (2004). Cognition and quality of life in patients with carotid artery occlusion. A follow-up study. Neurology, 62, 2230–5.
Bornstein, R., Benoit, B. G. & Trites, R. L. (1981). Neuropsychological changes following carotid endarterectomyCanadian Journal of Neurological Science, 8, 127–32.
CAVATAS investigators. (2001). Endovascular versus surgical treatment in patients with carotid stenosis in the carotid and vertebral transluminal angioplasty study (CAVATAS): a randomised trial. Lancet, 357, 1729–37.
Crawley, F., Clifton, A., Buckenham, al. (1997). Comparison of hemodynamic cerebral ischemia and microembolic signals detected during carotid endarterectomy and carotid angioplasty. Stroke, 28, 2460–4.
Crawley, F., Stygall, J., Lunn, al. (2000). Comparison of microembolism detected by transcranial Doppler and neuropsychological sequelae of carotid surgery and percutaneous transluminal angioplasty. Stroke, 31, 1329–34.
Dardik, A., Minor, J., Watson, C. & Hands, L. J. (2001). Improved quality of life among patients with symptomatic carotid artery disease undergoing carotid endarterectomy. Journal of Vascular Surgery, 33, 329–33.
European Carotid Surgery Trialists Collaboration Group (ECST). (1998). Randomized trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial. Lancet, 351, 1379–87.
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study (ACAS). (1995). Endarterectomy for asymptomatic carotid artery disease. JAMA: Journal of the American Medical Association, 273, 1421–8.
Gaunt, M. E., Martin, P. J., Smith, J. al. (1994). Clinical revelance of intraoperative embolization detected by transcranial Doppler ultrasonography during carotid endarterectomy: a prospective study of 100 patients. British Journal of Surgery, 81, 1435–9.
Grace, P. A. (2004). Fifty years of carotid surgery – hail and farewell?Irish Journal of Medical Science, 173, 75–7.
Hallin, A., Bergqvist, D., Fugl-Meyer, K. & Holmberg, L. (2002). Areas of concern, quality of life and life satisfaction in patients with peripheral vascular disease. European Journal of Vascular and Endovascular Surgery, 24, 255–63.
Heyer, E. J., Adams, D. C., Solomon, R. al. (1998). Neuropsychometric changes in patients after carotid endarterectomy. Stroke, 29, 1110–15.
Inzitari, D., Eliasziw, M., Gates, al. (2000). The causes and risk of stroke in patients with asymptomatic internal carotid artery stenosis. New England Journal of Medicine, 342, 1693–700.
Irvine, C. D., Gardner, F. V., Davies, A. H.&Lamont, P. M. (1998). Cognitive testing in patients undergoing carotid endarterectomy. European Journal of Vascular and Endovascular Surgery, 15, 195–204.
Jansen, C., Ramos, L. M. P., Heesewijk, M. al. (1994). Impact of microembolism and hemodynamic changes in the brain during carotid endarterectomy. Stroke, 25, 992–7.
Johnston, S. C., O'Mara, E. S., Manolio, T. al. (2004). Cognitive impairment and decline are associated with carotid artery disease in patients without clinically evident cerebrovascular disease. Anals of Internal Medicine, 140, 237–47.
Lloyd, A., Hayes, P. D., London, N. J. M., Bell, P. R. F. & Naylor, A. R. (2004). Does carotid endarterectomy lead to a decline in cognitive function or health related quality of life?Journal of Clinical and Experimental Neuropsychology, 26, 817–25.
Lunn, S., Crawley, F., Harrison, M. J. G., Brown, M. M. & Newman, S. P. (1999). Impact of carotid endarterectomy upon cognitive functioning. A systematic review of the literature. Cerebrovascular Diseases, 9, 74–81.
Mathiesen, E. B., Waterloo, K., Joakimsen, al. (2004). Reduced neuropsychological test performance in asymptomatic carotid stenosis. Neurology, 62, 695–701.
MRC Asymptomatic Carotid Surgery Trial (ASCT) Collaborative Group. (2004). Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: Randomised controlled trial. Lancet, 363, 1491–1502.
North American Symptomatic Carotid Endarterectomy Trial Collaborators (NASCETC). (1991). Beneficial effect of carotid endarterectomy in symptomatic patients with high grade carotid stenosis. New England Journal of Medicine, 325, 445–53.
Rabe, K. & Sievert, H. (2004). Carotid artery stenting: state of the art. Journal of Interventional Cardiology, 17, 417–26.
Rao, R. (2002). The role of carotid stenosis in vasular cognitive impairment. Journal of the Neurological Sciences, 203–204, 103–7.
Salenius, J. P., Harju, E., Kuukasjarvi, P., Haapanen, A. & Riekkinen, H. (1990). Late results of surgical and nonoperative treatment of carotid stenosis. Eighty-four patients documented by angiography in 1974–1976. Journal of Cardiovascular Surgery: Torino, 31, 156–61.
Sivaguru, A., Gaines, P. A., Beard, J. & Venerables, G. S. (1999). Neuropsychological outcome after carotid angioplasty: a randomised control trial. Journal of Neurology, Neurosurgery and Psychiatry, 66, 262 (Abstract).
Sirkka, A., Salenius, J. P., Portin, R. & Nummenmaa, T. (1992). Quality of life and cognitive performance after carotid endarterectomy during long-term follow-up. Acta Neurologica Scandinavica, 85, 58–62.
Smith, J. L., Evans, D. H., Gaunt, M. al. (1998). Experience with transcranial Doppler monitoring reduces the incidence of particulate embolization during carotid endarterectomy. British Journal of Surgery, 85, 56–9.
Trudel, L., Fabia, J. & Bouchard, J. P. (1984). Quality of life of 50 carotid endarterectomy survivors: a long term follow up study. Archives in Physical Medicine and Rehabilitation, 65, 310–12.
Vriens, E. M., Post, M. W., Jacobs, H. al. (1998). Changes in health-related quality of life after carotid endarterctomy. European Journal of Vascular and Endovascular Surgery, 16, 395–400.
Winslow, C. M., Solomon, D. H., Chassin, M. al. (1988). The appropriateness of carotid endarterectomy. New England Journal of Medicine, 318, 721–7.