General Surgery · Year 3 · from General Surgery

Case 3: Carotid Artery Stenosis

Patient Demographics

  • Age: 71 years
  • Sex: Male
  • Occupation: Retired professor

Chief Complaint

"I had an episode where I couldn't see out of my right eye for a few minutes."

History of Present Illness

The patient experienced sudden onset of complete vision loss in his right eye 3 days ago. He describes it as "a curtain coming down" over his vision. The episode lasted approximately 5-8 minutes, then resolved completely. He felt well otherwise during and after the episode. He has no residual visual symptoms. He presented to his ophthalmologist who noted normal exam and referred him for carotid evaluation. He denies weakness, numbness, speech difficulty, or other neurological symptoms.

Past Medical History

  • Hypertension
  • Hyperlipidemia
  • Type 2 diabetes
  • Coronary artery disease (2-vessel disease, medically managed)
  • Former smoker (40 pack-years, quit 10 years ago)

Medications

  • Aspirin 81 mg daily
  • Atorvastatin 80 mg daily
  • Metoprolol 50 mg daily
  • Lisinopril 20 mg daily
  • Metformin 1000 mg BID

Physical Examination

  • Vitals: BP 138/82, HR 66
  • Neurological exam: Completely normal, no deficits
  • Eyes: Visual acuity normal, fundoscopy - possible cholesterol embolus (Hollenhorst plaque) in right retinal artery
  • Neck: Right carotid bruit present
  • Cardiac: Regular rhythm, no murmurs

Diagnosis

Amaurosis fugax (transient monocular vision loss) - a form of transient ischemic attack (TIA) suggesting embolic source from right internal carotid artery

Imaging Workup

Carotid Duplex Ultrasound:

  • Right internal carotid artery: 80-90% stenosis
  • Left internal carotid artery: 40% stenosis
  • Bilateral atherosclerotic plaque

CT Angiography (Head and Neck):

  • Confirms right ICA stenosis: 85% (NASCET criteria)
  • Ulcerated plaque
  • Left ICA: 40% stenosis
  • Intracranial vessels: No significant stenosis
  • No evidence of acute infarct

MRI Brain:

  • No acute infarct
  • Small chronic lacunar infarcts (microvascular disease)
  • No large territory deficits

Risk Assessment

  • Symptomatic carotid stenosis (recent amaurosis fugax)
  • High-grade stenosis (85%)
  • Stroke risk without intervention: 20-26% at 2 years (NASCET data)
  • Strong indication for revascularization

Treatment Options

  1. Carotid endarterectomy (CEA): Gold standard for symptomatic stenosis
  2. Carotid artery stenting (CAS): Alternative, especially if high surgical risk
  3. Medical therapy alone: For patients with prohibitive surgical risk

Preoperative Assessment

  • Cardiology clearance (acceptable risk for CEA)
  • No significant contralateral carotid disease that would affect clamping
  • Good surgical anatomy

Decision

Carotid endarterectomy (CEA) chosen - standard of care for symptomatic high-grade stenosis with acceptable surgical risk

Operative Procedure

Right Carotid Endarterectomy:

  • General anesthesia with EEG monitoring
  • Longitudinal arteriotomy from common carotid to ICA beyond plaque
  • Shunt NOT required (adequate collateral flow)
  • Complete endarterectomy with eversion technique
  • Primary closure (no patch required given adequate vessel size)
  • Completion duplex: Widely patent, no residual disease

Pathology

  • Atherosclerotic plaque with ulceration and intraplaque hemorrhage
  • High-risk features for embolization

Postoperative Course

  • Neuro checks every 2 hours x 24 hours
  • Blood pressure strictly controlled (avoid hyperperfusion syndrome)
  • No neurological deficits
  • Discharged POD 2

Post-Procedure Management

  • Continue aspirin indefinitely
  • High-intensity statin therapy
  • Blood pressure optimization
  • Diabetes management
  • Surveillance duplex at 1 month, 6 months, then annually

Teaching Points

  1. Amaurosis fugax (transient monocular blindness) is a TIA and warrants urgent evaluation
  2. Symptomatic carotid stenosis >70% benefits from revascularization (NASCET trial)
  3. CEA should be performed within 2 weeks of symptoms for maximum benefit
  4. Hollenhorst plaques = cholesterol emboli from carotid plaque
  5. Medical therapy alone (aspirin + statin + BP control) is adjunct, not replacement for intervention in symptomatic high-grade stenosis
  6. Complications of CEA: Stroke, cranial nerve injury, MI, hyperperfusion syndrome

Clinical Image

Image Description: Carotid duplex ultrasound with Doppler demonstrating high-grade stenosis of the internal carotid artery. The elevated peak systolic velocity and turbulent flow pattern are consistent with significant narrowing exceeding 70%.

Attribution: Image from Wikimedia Commons, Category:Ultrasound images. Source: https://commons.wikimedia.org/wiki/Category:Ultrasound_images

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