Nesvs 2013 Postgraduate Course Self-assessment Exam

Simultaneous Carotid revascularization (CEA/CABG) is not supported by Level 1 evidence for asymptomatic patients with 80% stenosis undergoing coronary revascularization.

The given correct answer states that new bright areas on diffusion weighted MRI only occur on the same side of the carotid intervention. This means that after carotid intervention, the new bright areas on diffusion weighted MRI are not observed on the opposite side of the intervention. This statement suggests that the microemboli causing these new bright areas are localized to the same side of the carotid intervention and do not spread to the other side.

The patient has asymptomatic recurrent stenosis in the RICA with 50-69% stenosis, which has been stable for the past two years. In this case, the best therapy would be optimal medical therapy alone and continued surveillance. This means that the patient should receive medication and lifestyle changes to manage their condition, without any invasive procedures such as redo carotid endarterectomy or carotid angioplasty and stenting. Since the stenosis has been stable and the patient is asymptomatic, the risk of complications from invasive procedures outweighs the potential benefits. Regular monitoring and medical management are sufficient in this case.

The correct answer is A and C. During carotid angioplasty and stenting trials, two types of embolic protection methods have been used. One method is the use of distal filters or baskets placed in the distal internal carotid artery in the neck, which helps to catch any emboli that may be released during the procedure. The other method is proximal occlusion with flow reversal systems placed in the common carotid artery, which redirects blood flow away from the carotid artery during the procedure to prevent emboli from reaching the brain. Therefore, options A and C are the correct choices as they describe the different types of embolic protection used during carotid angioplasty and stenting trials.

The correct answer is NASCET. NASCET (North American Symptomatic Carotid Endarterectomy Trial) was conducted to evaluate the effectiveness of carotid endarterectomy (CEA) in patients with symptomatic carotid artery stenosis, not asymptomatic carotid artery stenosis. Therefore, it does not support the use of CEA for the management of asymptomatic carotid artery stenosis. ACAS (Asymptomatic Carotid Atherosclerosis Study), ACST (Asymptomatic Carotid Surgery Trial), and CREST (Carotid Revascularization Endarterectomy versus Stenting Trial) are trials specifically designed to assess the use of CEA in asymptomatic carotid artery stenosis.

The correct answer is Coumadin for anticoagulation for her PAD and carotid stenosis. Coumadin (warfarin) is not typically used for anticoagulation in peripheral arterial disease (PAD) and carotid stenosis. Instead, antiplatelet agents like aspirin are commonly used to prevent clot formation. Smoking cessation is important to reduce the risk of further arterial disease progression. Atorvastatin is a statin medication used to manage cholesterol levels, which is beneficial in reducing the risk of cardiovascular events in patients with PAD and carotid stenosis.

The correct answer is A and B. The explanation for this answer is that the question is asking for the upcoming or current carotid stent trials in the United States involving CAS (carotid artery stenting). The ROADSTER trial involves the use of direct cervical carotid access and flow reversal, while the CREST II trial aims to evaluate CAS versus CEA (carotid endarterectomy) versus best medical therapy for carotid stenosis. Therefore, options A and B are the correct choices as they both involve carotid stent trials in the United States.

The potential high risk criteria for inclusion in ongoing carotid angioplasty and stenting trials include previous CEA (carotid endarterectomy), prior neck irradiation, high bifurcation with difficult to access distal endpoint, and contralateral ICA (internal carotid artery) occlusion. However, a history of previously treated coronary artery disease with normal ejection fraction is not considered a high-risk criterion for inclusion in these trials.

The 2011 SVS Guidelines state that CAS is not indicated in asymptomatic patients outside of clinical trials. Therefore, the statement "CAS is indicated in some asymptomatic low risk patients outside of clinical trials" is not true.

There is significant regional variation in the use of CAS (carotid angioplasty and stenting) and CEA (carotid endarterectomy) to manage carotid artery stenosis in the United States. This means that different regions in the country have different preferences and practices when it comes to these treatments. The statement does not provide information about the frequency of CEA for symptomatic or asymptomatic carotid artery disease, the frequency of CAS performed by vascular surgeons or cardiologists, or the percentage of carotid artery interventions that are comprised of carotid angioplasty and stenting.

Using a flow reversal system for CAS offers several potential benefits. These include decreased risk of microemboli to the brain, the ability to have cerebral protection in place before crossing the stenosis with a guide wire, the ability to use any FDA approved carotid stent, and active aspiration of debris or in line flow reversal to minimize the risk of atheroembolization. However, it does not provide the benefit of lower profile devices and smaller sheath size.

The CREST trial did not demonstrate a lower overall incidence of stroke for CAS (carotid artery stenting) compared to CEA (carotid endarterectomy).

Transcranial Doppler (TCD) is a procedure that uses an ultrasound probe to assess blood flow in the intracerebral vessels through the frontal bone window. It can be used to determine the directionality of flow in specific arteries, such as the middle cerebral artery. This means that TCD can help identify the direction in which blood is flowing in the middle cerebral artery, which is important for evaluating blood flow patterns and detecting any abnormalities. The statement is true because TCD can indeed assess the directionality of flow in the middle cerebral artery.

The given correct answer is "Carotid angioplasty and stenting for 80% stenosis in an asymptomatic low-risk patient outside of a clinical trial." This treatment scenario is not eligible for reimbursement from Medicare under current CMS reimbursement guidelines. The guidelines specify that carotid angioplasty and stenting are only eligible for reimbursement in symptomatic high-risk patients or in asymptomatic patients with contralateral carotid occlusion. Asymptomatic low-risk patients do not meet the criteria for reimbursement in this scenario.

The CREST trial, a study comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA), found that the rate of stroke/death and myocardial infarction (MI) was not different between the two procedures. This means that the risk of these complications was similar whether patients underwent CAS or CEA. Additionally, the trial did not exclusively include asymptomatic patients, as indicated by the statement that the rate of stroke/death for all patients was higher in CAS compared to CEA. Therefore, the correct answer is "Only A and B."

The combination of Aspirin 325 and Plavix 75 mg is not preferred as an initial antithrombotic treatment in patients with non-obstructive atherosclerotic disease and TIA's who have no prior antiplatelet therapy. The other options listed, such as Aspirin 81 mg, Plavix 75 mg in aspirin intolerant patients, Aspirin and dipyridamole combination, and Aspirin 325 mg, may be considered as initial antithrombotic treatments in these patients.

The given statement that is not true is "In these studies only patients with severe (70-89%) and critical (> 90%) stenoses were included". This is because the previous statements mention that medical intervention alone is the best method to prevent stroke in asymptomatic patients and that the rate of stroke with medical intervention has fallen over the past 2 decades. Therefore, it implies that these studies included patients with various degrees of carotid stenosis, not just severe and critical stenoses.

The correct answer is "Attestation that all patients are seen by a vascular surgeon who determines that they are too high risk for an open procedure." This criterion is listed as a potential requirement when applying to become a CMS approved center to perform and be reimbursed for CAS. It ensures that patients who undergo CAS have been evaluated by a vascular surgeon and deemed too high risk for an open procedure. This helps to ensure patient safety and appropriate selection of candidates for CAS.