Internal carotid artery strictures can also be caused by fibromuscular dysplasia, in which constriction of the artery results from fibrous transformation of the media. Depending on the length of the vessel segment affected, the artery can be either patched or replaced. Segmental replacement of the carotid artery may be necessary in some cases for aneurysms, injuries, lesions resulting from prior radiation therapy, and after TEA with limited residual vascular wall. Autologous greater saphenous vein should be used for this purpose if possible. Replacement with a thin-walled polytetrafluoroethylene (PTFE) prosthesis is also possible in exceptional cases.
Prospects
CEA is currently the gold standard in the treatment of high-grade symptomatic and asymptomatic carotid stenoses. CAS has now entered clinical practice as a competitive procedure that is attractive for patients since it is less invasive, and may have some advantages over the established method of CEA in individual cases. While the trial data comparing the procedural safety of CAS to CEA are mixed due largely to probable methodological issues in individual trial conduct, there nevertheless is ample and growing data that long-term stroke prevention is equal between the two procedures out to at least 4 years and likely beyond. Several current studies nearing completion (the CREST, SPACE-2, and CAVATAS-2 trials) should provide a clearer picture as to the place CAS has in the management of carotid bifurcation disease. However, an indication for CAS may be considered after interdisciplinary consultation in individual cases in patients who are at high risk (e.g., with recurrent stenoses, radiogenic stenoses, contralateral recurrent nerve paralysis, etc.), or in the context of controlled studies.
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