Part 2 book “Vascular and endovascular surgery at a glance” has contents: Carotid surgery, other aneurysms, amputation and rehabilitation, the acute limb, primary hyperhidrosis, coagulopathy and thrombophilia, deep venous thrombosis, vascular ulceration, general wound care, the diabetic foot, haemodialysis access, and other ccontents. | 26 Carotid disease: Assessment and treatment Figure Signs and symptoms of stroke by vascular territory. Carotid territory Vertebrobasilar territory Ataxia Hemimotor/hemisensory deficit Diplopia Amaurosis fugax (direct retinal embolus) Homonymous hemianopia Gait abnormalities Higher cortical dysfunction 80% ischaemic 20% haemorrhagic Internal carotid artery External carotid artery Vertebral artery Figure Duplex assessment of the carotid artery. Duplex Stenosis < 50% 50–70% 70–99% 100% BMT BMT with surgery or stenting Abbreviations: BMT, best medical therapy Vascular and Endovascular Surgery at a Glance, First Edition. Morgan McMonagle and Matthew Stephenson. 62 © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd. Companion website: Overview Investigations After heart disease then cancer, stroke is the third leading cause of death in the Western world. 20% of strokes are haemorrhagic, 80% are ischaemic – mostly due to embolus but some due to small vessel disease in the brain and occasionally from prothrombotic disorders such as myeloma or sickle cell. Main sources of emboli: • Left atrium or ventricle (‘cardiogenic’). • Aortic arch. • Middle cerebral artery. • Carotid artery. • Vertebral artery. It is disease in the carotid artery that has relevance to vascular surgery. A stenosis in the carotid causes problems because there is potential debris that could embolise to the cerebral circulation (the reduced flow to the brain from the stenosis is of relatively little significance because there is good collateral supply). All patients presenting with a stroke or TIA should have Duplex U/S of their carotid arteries within 24 hours (as an aside, a carotid bruit is of little clinical significance because it has low sensitivity and low specificity). This indicates the % stenosis. • <50% – no indication for surgery. • 50–70% – moderate benefit from surgery. • 70–99% – significant benefit from
