Current indications & therapies for Carotid Artery Stenosis

Carotid Artery Stenosis & Stroke

Current Indications and Therapies

Stroke Facts

Every 45 seconds someone in the USA has a stroke

Annually 46,000 more women than men have a stroke

1 out of every 15 deaths in the USA are because of a stroke

Mean lifetime cost of ischemic stroke is $140,078

What is Carotid Artery Disease?

A type of peripheral arterial disease Narrowing in the carotid artery Atherosclerotic plaque accumulates over

time Most frequently observed at the carotid

bifurcation

A Risk Factor for Stroke

Plaque or clot breaks off from the carotid & blocks a smaller artery in the brain

Narrowing of the carotids due to plaque build-up

A clot becomes wedged in a carotid artery narrowed by plaque

Stroke Symptoms

Sudden weakness of face/arm/leg, especially on one side of the body

Abrupt onset of confusion, trouble speaking or understanding

Sudden double vision or vision problems Abrupt onset of dizziness/loss of balance or

coordination Sudden and severe headache

Carotid Artery Disease Symptoms

Bruit in the affected carotid artery TIA Amarurosis Fugax – temporary blindness in

one eye IMPORTANT: Patients may NOT have any

symptoms

Diagnostic Tools for Carotid Artery Disease

H & P Duplex Ultrasound of the carotids Computed Tomographic Angiography (CTA)

of the neck Magnetic Resonance Angiography (MRA) of

the carotids Carotid Angiography

Duplex Ultrasound Advantages

Non-invasive and painless Widely available Locate and determine degree of lesion

stenosis Post-procedure follow-up tool May give information on the plaque

characteristics

Duplex Ultrasound - Disadvantages

Operator dependent results Tendency for overestimating lesion Calcium may obscure lesion

CTA - Advantages

More precise than a MRA or ultrasound

Safer

Less time consuming

Less invasive that conventional angiography

CTA - Disadvantages

Contrast Nephrotoxicity Allerigc reaction to contrast More complex and expensive than

ultrasound Not widely used compared to ultrasound Patient motion affects image quality

MRA - Advantages

Non-invasive and safer than carotid angiogram

No intra-arterial catheterization

No exposure to x-rays

Procedure and recovery times are shorter that carotid angiography

Allergic reaction to contrast is minimal

Kidney damage from contrast is rare

MRA - Disadvantages

Claustrophobic patients will have to be pre-medicated

Interaction with pacemakers and other metallic implants

Does not image calcium well Very tight stenosis may be difficult to

distinguish from an occulsion

Carotid Angiography - Advantages

Clear & accurate vessel visualization Diagnosis & treatment in a single procedure

Carotid Angiography - Disadvantages

Risk of stroke associated with carotid angiogram

Relatively expensive and invasive Potential for allergic reaction to the dye nephrotoxic

Dr. Anain’s diagnostics

Carotid duplex If the patient is at moderate risk for Carotid

Artery Endarterectomy then a MRA/CTA If the patient is high risk for Carotid Artery

Endarterectomy then: Carotid Angiogram

Treatment Modalities

Medical Therapy Carotid Endarterectomy (CEA) Carotid Artery Stenting (CAS)

Medical Treatment

To reduce the risk of future stroke: Control hypertension, diabetes, and weight Stop smoking Lower cholesterol Increase exercise

Medical Treatment

Serial carotid duplex ultrasounds to monitor the disease

Antiplatelet – Aspirin, Plavix Anticoagulation – coumadin Statin

CEA – Carotid Endarterectomy

To reduce the risk of stroke Surgically remove plaque Arteriotomy at the stenotic section of the

carotid Plaque is manually removed Closure of arteriotomy

CEA Advantages

Proven effective in low surgical risk patients Safe and effective (with an experienced

surgeon) Decreases the risk of stroke

CEA - Disadvantages

Surgery and neck incision therefore longer recovery time

Risk with general anesthesia Potential for emboli and cause stroke Cranial nerve palsy (X and XII) Infection Unproven indication in high surgical risk

candidates

CAS – Carotid Artery Stenting

Endovascular stent placement via stab wound in the groin

For plaque stabilization to reduce the risk of future stroke

CAS

Use of embolic protection placed in carotid artery to reduce the chance of peri-procedure complications (throwing a clot into brain)

Placement of a self-expanding stent to trap or exclude the plaque

Devices (embolic protection) and catheters are removed while the stent remains and the access site (groin) bleeding is managed with a vascular closure device in the wound and a pressure dressing

CAS - Advantages

If patient has contraindication for a CEA (already had a CEA, multiple diseases and a high surgical risk)

Stabilizes the plaque to minimize risk of embolization

Avoids the risk of cranial nerve damage Does not require general anesthesia Option for patients

CAS - Disadvantages

Potential for embolization resulting in stroke Not all patients are suitable for stenting: Severe aortic arch and supra-aortic vessel

tortuosity Thrombus String sign present Patients with very long & severe lesions Heavy all around calcification of the artery

Carotid Endarterectomy-outcomes

Adequate cerebral blood flow Pain controlled Evidence of normal wound healing Know ways to slow the progression of

atherosclerosis Know S&S to report Understand follow-up care

Nursing Diagnoses

Pre-op ineffective cerebral perfusion Post-op potential complications: cerebral

ischemia, respiratory distress, cranial nerve damage (facial VII, hypoglossal XII, glossopharyngeal IX, Vagus X, Accessory XI)

Deficient knowledge, ineffective therapeutic regimen management, or ineffective health maintenance

Nursing DX: Ineffective Tissue Perfusion Cerebral

Partial or complete occulsion of the carotid artery by atherosclerotic plaque and/or thrombus

A cerebral embolus associated with dislodgment of atherosclerotic plaque or a thrombus from the carotid artery

Nursing DX: Ineffective Tissue Perfusion Cerebral – Desired Outcome

Maintain adequate cerebral tissue perfusion as evidenced by:

Mentally alert and orientates Absence of dizziness, visual disturbances,

and speech impairments Normal motor and sensory function

Report Symptoms of Carotid Artery Occlusion and/or cerebral embolization

Agitation Lethargy Confusion Dizziness Slurred speech Expressive aphasia Paresthesias

Measures to maintain adequate cerebral tissue perfusion

Administer antiplatelet agents to prevent new or extended thrombus formation and further occulsion of the carotid artery

Avoid activities that create a Valsalva response (strain with BM, holding breath while moving up in bed)

Prevent HTN to reduce risk of cerebral embolism by reduce stress, give antihypertensives

If Symptoms of decreased cerebral perfusion occur

Maintain of bed rest Head of bed flat unless contraindicated Anticoagulants (IV Heparin, Lovenox,

warfarin Provide emotional support to patient and

family Symptoms usually necessitates postponement of planned surgery

Potential Complications of Carotid Endarterectomy – Cerebral Ischemia

Prolonged artery clamp time during surgery and/or vasospasm associated w/clamping and manipulation of cerebral vessels

Hypotension associated w/hypovolemia from blood loss and IV Dextran commonly used

Embolization during or after surgery and/or formation of a thrombus at surgical site

Potential Complications of Carotid Endarterectomy – Respiratory Distress

Airway obstruction associated w/tracheal compression which can occur as a result of inflammation,

edema, and/or hematoma formation in the surgical

area of the neck

Potential Complications of Carotid Endarterectomy – Cranial Nerve Damage

Facial VII, hypoglossal XII, glossopharyngeal IX, Vagus X, and/or accessory nerves XI

Related to surgical trauma and/or compression of the nerves as a result of inflammation, edema, and/or hematoma formation

Observe for TIA or stroke symptoms

Nursing Actions to maintain adequate cerebral blood flow – post op

Report S&S of excessive site bleeding (new or expanding hematoma, continued bright red bleeding from incision and wound drain

Report decreasing Hgb levels Report S&S of hypovolemic shock Report S&S cerebral ischemia TIA/stroke

symptoms

Implement measures to prevent cerebral ischemia – reduce pressure on carotid vessels

Reduce operative site inflammation and/or edema: HOB up, ice pack to incision as ordered

Maintain patency of wound drain: free of kinks and emptied as often as necessary

Instruct pt to avoid turning head abruptly or hyperextending neck to reduce stress on suture line and prevent a hematoma

Implement measures to prevent cerebral ischemia – reduce pressure on carotid vessels

Caution pt to avoid activities that create a Valsalva response to prevent dislodgment of exisitng thrombi and reduce stress and bleeding from suture line

Maintain blood pressure within a safe range w/ antihypertensives

HTN may occur as a result of underlying disease processes or damage to the carotid sinus baroreceptors during surgery

Implement measures to prevent cerebral ischemia – reduce pressure on carotid vessels

Control HTN to prevent rupture of the operative vessel or reduce risk of dislodgment of any existing thrombus

To treat hypotension consider sympathomimetics (dopamine) and transfer to ICU if on drip

Patient will not experience respiratory distress – assess for & report

Increased edema or expanding hematoma in surgical area

Deviation of trachea from midline New or increased difficulty swallowing S&S of respiratory distress: restlessness, agitation,

rapid and/or labored breathing, stridor, sternocleidomastoid muscle retraction

Significant decrease in pulse oximetry results

Thank You

For your kind attention From: Bridget Foster,RN Christina Palmeri, RN,

Tonya Salter, RN, Lana Pasek, NP, the staff of 3 North of Sister’s of Charity Hospital and Paul Anain, MD of the Endovascular and Vascular Center of Western New York