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Patients with no neurologic symptoms but with carotid stenosis on imaging will benefit from carotid intervention if they are considered to be at low risk for intervention and their expected survival is greater than 5 years Recommendation for intervention also presumes that the treating institution has a stroke rate in asymptomatic patients that is acceptable (< 3%) Large studies indicate a reduction in stroke from 115% to 50% over 5 years with surgical treatment of asymptomatic carotid stenoses of greater than 60% However, the usual practice is to only treat those patients who have greater than 80% stenosis

Prognosis for patients with carotid stenosis who have had a TIA or small stroke is poor without treatment; 25% of these patients will have a stroke with most of the events occurring in the first year of follow-up Patients with carotid stenosis without symptoms have an annual stroke rate of just over 2% Risk factor modification with antiplatelet agents is not nearly as effective in preventing stroke as removing the stenosis Symptomatic patients most likely have unstable plaques with ulceration or they have had a recent progression of the stenosis This suggests that prospective ultrasound screening would be valuable in timing intervention in asymptomatic patients Approximately 10% of asymptomatic patients have evidence of plaque progression in a given year Concomitant coronary artery disease is common and is an important factor in these patients both for perioperative risk and long-term prognosis Aggressive risk factor modification should be prescribed for patients with cerebrovascular disease regardless of planned intervention

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Mas JL et al; EVA-3S Investigators Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis N Engl J Med 2006 Oct 19;355(16):1660 71 [PMID: 17050890] Safian RD et al; CREATE Pivotal Trial Investigators Protected carotid stenting in high-risk patients with severe carotid artery stenosis J Am Coll Cardiol 2006 Jun 20;47(12):2384 9 [PMID: 16781363]

Patients with TIAs or strokes from which they have completely or nearly completely recovered will benefit from carotid intervention if the carotid stenosis, ipsilateral to the event, has a stenosis of 70%, and they are likely to derive benefit with a stenosis of 50 69% In these situations, carotid endarterectomy has been shown to have a durable effect in preventing further events

A service contract integrates with the CS (Customer Service) module in ECC This permits the CS module to arrange the technicians for the service in accordance with the service contract Should a service that was not initially part of the original service agreement be completed, it may be billed with a billing request (Sales Document type LV may be copied) The item category used by service contracts is very important It is best to understand the business before you try and customize it The service item can be any one of the following: A service task, once off A material used in the service Time charged for a technician s hourly rate The standard item category for a service is WVN You may need additional item categories because of the different types of items available on a service contract Remember to copy this standard and change the necessary fields The standard item category has been created to represent a service that is carried out and billed periodically, as seen in Figure 4-9 with billing plan I The standard item category has a completion rule C, which determines the item to be fully referenced when target quantity is fully reached This particular item category is relevant for order-related billing according to a billing plan, as well as utilizing a billing plan type 02, which indicates periodic billing

The primary complication of carotid intervention is stroke due to embolization of plaque material during the procedure The American Heart Association has recommended upper limits of acceptable combined morbidity and mortality for these interventions: 3% for asymptomatic, 5% for those with TIAs, and 7% for patients with previous stroke Results that do not match these guidelines will jeopardize the therapeutic benefit of carotid intervention

In addition to stroke risk, carotid endarterectomy carries a 10% risk of transient cranial nerve injury (usually the vagus or hypoglossal nerve) and 1 2% risk of permanent deficits There is also the risk of postoperative neck hematoma, which can cause acute compromise of the airway Coronary artery disease exists as a comorbidity in most of these patients Myocardial infarction rates after carotid endarterectomy are approximately 5%

VISCERAL ARTERY INSUFFICIENCY (INTESTINAL ANGINA)

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