Endarterectomy for symptomatic internal carotid artery web

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  • 1 School of Medicine and Dentistry, University of Rochester, New York;
  • | 2 Department of Radiology, Section of Neurointerventional Radiology,
  • | 3 Department of Neurosurgery,
  • | 4 Department of Pathology, Section of Neuropathology, and
  • | 5 Department of Neurology, NYU Langone Health, New York, New York; and
  • | 6 Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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OBJECTIVE

The carotid web (CW) is an underrecognized source of cryptogenic, embolic stroke in patients younger than 55 years of age, with up to 37% of these patients found to have CW on angiography. Currently, there are little data detailing the best treatment practices to reduce the risk of recurrent stroke in these patients. The authors describe their institutional surgical experience with patients treated via carotid endarterectomy (CEA) for a symptomatic internal carotid artery web.

METHODS

A retrospective, observational cohort study was performed including all patients presenting to the authors’ institution with CW. All patients who were screened underwent either carotid artery stenting (CAS) or CEA after presentation with ischemic stroke from January 2019 to February 2020. From this sample, patients with suggestive radiological features and pathologically confirmed CW who underwent CEA were identified. Patient demographics, medical histories, radiological images, surgical results, and clinical outcomes were collected and described using descriptive statistics.

RESULTS

A total of 45 patients with symptomatic carotid lesions were treated at the authors’ institution during the time period. Twenty patients underwent CAS, 1 of them for a CW. Twenty-five patients were treated via CEA, and of these, 6 presented with ischemic strokes ipsilateral to CWs, including 3 patients who presented with recurrent strokes. The mean patient age was 55 ± 12.6 years and 5 of 6 were women. CT angiography or digital subtraction angiography demonstrated the presence of CWs ipsilateral to the stroke in all patients. All patients underwent resection of CWs using CEA. There were no permanent procedural complications and no patients had stroke recurrence following intervention at the latest follow-up (mean 6.1 ± 4 months). One patient developed mild tongue deviation most likely related to retraction, with complete recovery at follow-up.

CONCLUSIONS

CEA is a safe and feasible treatment for symptomatic carotid webs and should be considered a viable alternative to CAS in this patient population.

ABBREVIATIONS

ACT = activated clotting time; CAS = carotid artery stenting; CEA = carotid endarterectomy; CTA = CT angiography; CW = carotid web; DSA = digital subtraction angiography; FMD = fibromuscular dysplasia; SMA = smooth muscle actin.
Illustrations from Marx and Schroeder (pp 318–326). Copyright Henry W. S. Schroeder. Published with permission.

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Contributor Notes

Correspondence Erez Nossek: NYU Langone Health, New York, NY. erez.nossek@nyulangone.org.

INCLUDE WHEN CITING Published online August 28, 2020; DOI: 10.3171/2020.5.JNS201107.

Disclosures Dr. Riina reports ownership in eVasc Neuro, MedTel, MediVis, ELum, and NTI; being a consultant to Medtronic; and being on the speaker’s bureau for Stryker.

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