What is the role of pharmacologic therapy in the treatment of atherosclerotic disease of the carotid artery?

Updated: Feb 21, 2019

Author: Jake F Hemingway, MD; Chief Editor: Vincent Lopez Rowe, MD more...

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Aspirin (30-1350 mg/day) irreversibly acetylates the cyclooxygenase of platelets, thus inhibiting platelet synthesis of thromboxane A2. Prostacyclin production in the endothelium is reduced, but this effect is reversible and short-lived. A reduction in transient ischemic attacks (TIAs), stroke, and death in men was shown in the Canadian Cooperative Study Group.^[15]

Statins, which include atorvastatin, rosuvastatin, simvastatin, pravastatin, and lovastatin, are 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors that lower LDL cholesterol levels. Statin therapy, with a target low-density lipoprotein (LDL) level below 100 mg/dL, is recommended for all patients with extracranial carotid atherosclerotic disease. A lower target LDL level, 70mg/dL, is recommended in high-risk patients.^[16]

Ticlopidine (250 mg q12hr) is a thienopyridine that irreversibly alters the platelet membrane and inhibits platelet aggregation. It is approximately 10% more effective than aspirin. Toxicity includes neutropenia and diarrhea. Clopidogrel (75 mg/day) is similar to ticlopidine; the risk of neutropenia is low.

Warfarin (titrated international normalized ratio [INR] 2-3) use in patients with noncardiac emboli is controversial.

Antiplatelet therapy (cilostazol) may reduce the progression of carotid artery stenosis after stent implantation.^[17]

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Media Gallery

Arteriogram of aortic arch and its branches.
Arteriogram of carotid stenosis.
Atherosclerotic plaque removed at time of carotid endarterectomy (areas of ulceration with thrombus and intraplaque hemorrhage are present).
Carotid artery exposed prior to carotid endarterectomy (coil present in internal carotid artery).
Carotid artery following endarterectomy and prior to closure (tapered endpoint and smooth appearance of lumen).
Carotid artery following Dacron patch angioplasty.
Selective left carotid angiogram.
Oblique view of left carotid artery demonstrating lesion within internal carotid artery.
Placement of stent into internal carotid artery. Note filter wire in upper photos (dots at top of internal carotid artery).
Angioplasty after stent placement; again, note filter wire protecting distal carotid artery.
Completion arteriogram displaying improvement in diameter of internal carotid artery.
Normal carotid arteries on color flow duplex ultrasonography.
Color flow duplex ultrasonogram reveals 80-99% left carotid stenosis and normal right carotid.
Carotid plaque.

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Author

Jake F Hemingway, MD Resident Physician in Integrated Vascular Surgery, Department of Surgery, University of Washington School of Medicine

Jake F Hemingway, MD is a member of the following medical societies: Society for Vascular Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Niten Singh, MD, FACS Associate Professor of Surgery, University of Washington School of Medicine; Director of Vascular Limb Preservation, Vascular Surgery Clinic at Harborview

Niten Singh, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Society for Vascular Surgery

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Surgical Association, Pacific Coast Surgical Association, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Western Vascular Society

Disclosure: Nothing to disclose.

Additional Contributors

April L Rodriguez, MD, MS Senior Resident, Integrated Vascular Surgery Residency, Department of Surgery, University of Washington School of Medicine

April L Rodriguez, MD, MS is a member of the following medical societies: American College of Surgeons, Society for Clinical Vascular Surgery, Vascular and Endovascular Surgery Society

Disclosure: Nothing to disclose.

Acknowledgements

David L Gillespie, MD, FACS, RVT, DMCC, COL, MC USA Chief and Program Director, Vascular Surgery Service, Walter Reed Army Medical Center; Professor of Surgery, Uniformed Services University of the Health Sciences; Vascular Surgery Consultant, Office of the US Army Surgeon General

David L Gillespie, MD, FACS, RVT, DMCC, COL, MC is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Venous Forum, Eastern Vascular Society, Society for Vascular Surgery, and Southern Association for Vascular Surgery

Disclosure: Nothing to disclose.

James M Goff, MD Assistant Chief, Department of Surgery, Walter Reed Army Medical Center; Assistant Professor, F Department of Surgery, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences

James M Goff, MD is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Sean D O'Donnell, MD Director, Department of Surgery, Section of Vascular and Endovascular Surgery, Washington Hospital Center

Sean D O'Donnell, MD is a member of the following medical societies: American College of Surgeons and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment