Carotid Endarterectomy Case Study
The Patient: 68-year-old female
Presented with: Carotid stenosis
A left carotid stenosis was first diagnosed in April 2005 after the patient experienced left facial numbness and a left carotid bruit was noticed by her primary healthcare provider. A duplex ultrasound revealed a moderate stenosis of 40 to 59 percent. Her past medical history is significant for diabetes mellitus, hypertension, and dyslipidemia.
Evaluated by: Vascular surgery team at the UVa Health System
A computed tomographic angiography (CTA) was performed during an outpatient visit. This study did not demonstrate a hemodynamically significant lesion, and the facial numbness had stopped. The treatment team recommended an anti-platelet medication for the patient and decided to have the patient return annually for continued surveillance of the lesion.
An ultrasound at the patient's next outpatient visit demonstrated worsening of the lesion to the 60 to 79 percent range, though the patient continued to be without symptoms. The treatment team decided to shorten the follow-up interval to six months.
Diagnosis: Stroke risk from severe stenosis
CTA at the next visit showed the left stenosis was between 73 and 82 percent occluded. A treatment team led by Nancy Harthun, M.D., recommended surgery to prevent the risk of stroke from this lesion.
"The doctors, all the UVa personnel were excellent," the patient says. She was especially pleased with "the way they explained things, their efficiency, and the good attitude everyone had."
Treatment: Carotid endarterectomy
The patient was admitted to the hospital the morning of surgery. The carotid artery was exposed and the plaque, which was nearly occluding the artery, was removed. Care was taken when closing the artery with a fabric (dacron) patch to prevent narrowing.
Outcome:
The patient recovered uneventfully and was discharged home the next morning. She continues to feel fine.
"I would recommend Dr. Harthun to anyone. I would recommend UVa to anyone," the patient says.
When to Refer
Patients should be referred for a carotid endarterectomy if they have:
- A 50 percent or greater carotid stenosis
- History of transient ischemic attack or stroke
- Amarosis fugax
- A bruit becoming tighter
Patients should be referred for screening for a carotid stenosis if they have any of the following risk factors:
- Hypertension
- Diabetes
- Family history of stroke
- High cholesterol
CEA at UVa
The UVa Health System performed 126 carotid endarterectomies from the fourth quarter of 2005 through the third quarter of 2006, according to Solucient.
According to a UVa study of CEAs performed in Virginia, hospitals performing an average of more than 100 CEAs annually had lower mortality and stroke rates along with shorter lengths of stay than hospitals performing fewer than 100 procedures. UVa's mortality index and average length of stay were better than the state average from the fourth quarter of 2005 through the third quarter of 2006, according to Solucient.
Carotid stenosis patients are cared for by a multidisciplinary team at UVa that features cardiologists and members of the stroke team at UVa's Primary Stroke Center, including stroke neurologists and interventional neuroradiologists.