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Blood Pressure Instability after Percutaneous Carotid Angioplasty and Stenting

Endovascular treatment of carotid stenosis by way of balloon angioplasty and carotid artery stenting (CAS) may be accompanied by bradycardia or hypotension. The incidence of CAS-induced bradycardia varies widely in the literature, ranging from 5% to 76%. Similarly, the incidence of hypotension resulting from endovascular carotid interventions showed a wide range from 14% to 28%, based on available reports. The wide disparity in the reported incidence…

Embolic Protection Devices to Prevent Stroke during Percutaneous Angioplasty and Stenting

The use of a cerebral protection device during carotid angioplasty and stenting (CAS) has been a component of most trials demonstrating the safety and efficacy of CAS, thereby suggesting that use of cerebral protection devices is standard practice. Currently, there are two basic mechanisms to provide cerebral embolic protection: interpose a distal protection device between the lesion and the cerebral vasculature to interrupt embolic debris dislodged…

Reversal of Cerebral Blood Flow to Prevent Stroke during Percutaneous Carotid Artery Angioplasty and Stenting

Embolization to the brain is a universal occurrence during carotid artery stenting (CAS) procedures. This has been documented by several well conducted ex vivo studies, by the routine use of transcranial Doppler monitoring, and by analyzing the blood aspirated after the use of distal occlusion balloons. It is also widely agreed upon that the goal of cerebral protection during CAS is to suppress or decrease the…

Technical Aspects of Percutaneous Carotid Angioplasty and Stenting for Arteriosclerotic Disease

Carotid angioplasty and stenting with cerebral protection has emerged as a minimally invasive alternative to endarterectomy and is a treatment option for carotid arteriosclerotic disease. Carotid angioplasty and stenting comprises the following steps: (1) preprocedural evaluation, (2) femoral access, (3) arch aortogram, (4) selective common carotid catheterization and angiogram, (5) carotid sheath access, (6) crossing of the carotid stenosis, (7) filter placement, (8) predilatation, (9) stenting,…

Selection of Patients for Carotid Endarterectomy versus Carotid Artery Stenting

Carotid endarterectomy (CEA) has been shown to decrease the long-term risk of stroke compared with medical therapy. Percutaneous techniques such as carotid artery angioplasty with stenting (CAS) are less invasive and a viable option for the treatment of carotid artery disease. The increased use of CAS to treat carotid artery disease has been questioned, mainly by the surgical community, because of the perceived superiority of CEA.…

Diabetes as a Risk Factor in Atherosclerotic Cerebrovascular Disease

Diabetes mellitus (DM) has been described as an epidemic in progress. By 2050 its prevalence among adults in the United States is predicted to increase from 1 in 10 to 1 in 5. Additionally, in the adolescent population its incidence is on the rise. DM results from either the absolute deficiency of insulin (type 1 [T1DM]) or resistance to the action of insulin (type 2 [T2DM]).…

Medical Therapy Including Fibrinolytic Therapy of Acute Ischemic Stroke

Despite expanding research and advancements in medical care, there are approximately 610,000 new first-attack strokes in the United States every year, resulting in nearly 136,000 deaths and adding to the total of 6.4 million Americans as stroke survivors. Of all strokes, an estimated 87% are ischemic. The common term “time is brain” used in describing stroke management implies that the cornerstone of medical therapy of acute…

Medical Treatment to Prevent Transient Ischemic Attacks and Ischemic Stroke

The distinction between a transient ischemic attack (TIA) and stroke is made by duration of symptoms: The duration of a TIA is less than 24 hours. A TIA is a harbinger of stroke in up to 17% of patients, most often during the first week after the event. Ischemic stroke accounts for 88% of all strokes. Classic subtypes of stroke have been well defined ( Box…

Transcranial Doppler in the Evaluation of Cerebrovascular Disease

Transcranial Doppler (TCD) ultrasonography is the only noninvasive real-time examination that adds important physiologic information to anatomic imaging studies when evaluating blood flow in major intracerebral vessels. It is considered an extension of the clinical neurologic examination, which includes ultrasound of the extracranial vessels. Introduced by Aaslid and colleagues in 1982 as a technique using ultrasound technology to record velocity measurements of cerebral arteries through the…

Duplex Scanning and Spectral Analysis of Carotid Bifurcation Atherosclerotic Disease

In the 1980s and 1990s, grading of the degree of internal carotid artery (ICA) stenosis with duplex scanning depended on Doppler velocities at the site of maximum stenosis. With increasing resolution and image quality of gray-scale images and better color flow, plaque imaging has become complementary to velocity measurements, and in certain cases, equally important. The aim of this chapter is to present the current state…

Magnetic Resonance Imaging and Positron Emission Tomography in the Evaluation of Cerebrovascular Disease

The evolution of diagnostic tools available to study cerebrovascular disease has advanced in recent years. Although some of the major tests aid in identifying occlusive or aneurysmal disease, especially in patients with contraindications to standard contrast studies, the newest techniques have the goal of identifying patients at higher risk for cerebrovascular events possibly related to plaque instability or inflammatory activity within the plaque. Among these diagnostic…

Arteriographic Evaluation of Cerebrovascular Disease

Catheter-based angiography is considered the gold standard for imaging the cerebral vasculature. The first report of x-ray angiography of vasculature was in 1896, performed in Vienna on a cadaveric specimen. The field has progressed dramatically since that time, with many important developments during the last 2 decades. Indications for Catheter-Based Angiography Diagnostic Indications Catheter-based angiography provides a very high spatial resolution (200–300 μm) with excellent temporal…

Giant Cell Arteritis

Giant cell arteritis (GCA), also called temporal arteritis, is characterized by granulomatous inflammation of large arteries. Although GCA predominantly involves the extracranial branches of the carotid artery, the aorta and its major branches can also be affected. GCA is a disease of the elderly, with a mean age at onset of about 75 years. It is a common form of vasculitis, with an estimated annual incidence…

Carotid Artery Kinks and Coils

Most anatomic descriptions of the cervical carotid artery note a straight course to the skull base free of branches. Although angulated cervical carotid arteries, especially the internal carotid artery (ICA), are a relatively common finding in adults (∼25%), the excessive elongation of the internal carotid artery in a confined space results in a curvature termed coiling. Kinking of the internal carotid artery also results from elongation…

Carotid Artery Dissections

Carotid artery dissections have been increasingly recognized over the last several decades. Their precise incidence is hard to estimate, but it ranges from 2.5 to 3/100,000 population. They account for 2% to 3% of first-time strokes but up to 20% of strokes in patients younger than 30 years. They have been reported in children and at times are bilateral. In the setting of major trauma with…

Pathology of Carotid Artery Atherosclerosis

Atherosclerosis is associated with a number of well-recognized systemic risk factors such as hyperlipidemia, hypertension, cigarette smoking, and diabetes mellitus. Atherosclerotic plaque formation is a localized rather than diffuse process, however, and preferentially affects certain segments of the arterial tree such as the carotid, coronary, and lower extremity arteries, while sparing others such as the upper extremity vessels. Arteriosclerotic plaques in the carotid circulation usually form…

Managing Complex Ventral/Parastomal Hernias in Colorectal Surgical Patients

Introduction Ventral hernias can occur after any abdominal incision. They are relatively common after open colorectal surgery, and patients with an abdominal stoma are particularly prone to the development of hernias. Patients with ventral hernias often present a complex surgical problem. In such patients, the effects of the prior surgeries combine with the difficulty of achieving a permanent repair of sometimes large or complex defects in…

Enhanced Recovery Pathways After Colorectal Surgery

Background Major surgery is usually followed by pain, stress-induced organ dysfunction, and catabolism. These sequelae increase the risk of cardiopulmonary, infectious, thromboembolic, and cognitive complications and functional impairment, prolong hospitalization, and require rehabilitation and readmission. The concept of “fast-track surgery” or “enhanced recovery programs” has evolved in response to the adverse effects of surgery and is based on a multimodal intervention encompassing all perioperative care principles.…