The role of advanced diagnostic technology in the selection of a patient with symptomatic but hemodynamically insignificant disease for carotid endarterectomy (original) (raw)
2015, Journal of Vascular Surgery Cases
Current Level I evidence demonstrates no benefit for carotid endarterectomy in symptomatic patients with <50% carotid stenoses. However, unstable plaque morphology is increasingly recognized in the genesis of ischemic cerebral events. New advanced imaging technology, such as contrast-enhanced magnetic resonance angiography and ultrasound imaging, are emerging as important adjuncts in the evaluation of this patient population. We present a case where both modalities were beneficial in identifying plaque instability manifested by intraplaque hemorrhage and neovascularization in a patient with recurrent cerebral ischemic events and hemodynamically insignificant carotid disease. (J Vasc Surg Cases 2015;1:90-3.) Level I evidence derived from the North American Symptomatic Carotid Endarterectomy Trial 1 and the European Carotid Surgery Trial 2 established the role of carotid endarterectomy (CEA) for patients with symptomatic >50% internal carotid artery (ICA) stenoses. Conversely, these investigations demonstrated no benefit for CEA for symptomatic patients with <50% stenoses compared with medical management. We recently encountered a patient with a unilateral hemodynamically insignificant ICA stenosis who experienced recurrent cerebral ischemic events despite maximum medical therapy and without other potential causes. On the basis of magnetic resonance angiography (MRA) and contrast-enhanced duplex findings, we proceeded with CEA. This case illustrates that rarely one may encounter a patient with an unstable plaque in the absence of hemodynamic significance and who should be managed with CEA. The patient consented to publication of this report.