From the Guidelines
The management of fibromuscular dysplasia (FMD) of the internal carotid artery should focus on annual noninvasive imaging and administration of platelet-inhibitor medication to prevent thromboembolism, with carotid angioplasty with or without stenting considered for patients with symptomatic disease. According to the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease 1, the following recommendations can be made:
- Annual noninvasive imaging of the carotid arteries is reasonable initially for patients with FMD to detect changes in the extent or severity of disease, although the effect on outcomes is unclear.
- Administration of platelet-inhibitor medication can be beneficial in patients with FMD of the carotid arteries to prevent thromboembolism, but the optimum drug and dosing regimen have not been established.
- Carotid angioplasty with or without stenting is reasonable for patients with retinal or hemispheric cerebral ischemic symptoms related to FMD of the ipsilateral carotid artery, but comparative data addressing these methods of revascularization are not available. It is essential to note that revascularization is not recommended for patients with asymptomatic FMD of a carotid artery, regardless of the severity of stenosis, as stated in the guideline 1. The natural history and pathophysiology of FMD are unknown, but symptoms are thought to result from reduced blood flow or thromboembolism, making prevention and monitoring crucial in the management of this condition.
From the Research
Management of Fibromuscular Dysplasia of the Internal Carotid Artery
The management of fibromuscular dysplasia (FMD) of the internal carotid artery involves various approaches, including medical therapy and surgical intervention.
- For asymptomatic lesions, antiplatelet medication is the accepted therapy 2, 3.
- Graduated endoluminal surgical dilation is no longer used in most medical centers, and current percutaneous angioplasty is the preferred treatment for symptomatic carotid FMD 2.
- Surgical treatment may be considered for symptomatic lesions, and it can prevent recurrent symptoms with an acceptably low morbidity and mortality 4, 3, 5.
- The surgical techniques used include graduated or balloon intra-luminal dilatation, either isolated or associated with resection-anastomosis, saphenous graft, and reconstructive aneurysmorrhaphy 5.
Medical Therapy
Medical therapy is often used to manage asymptomatic FMD of the internal carotid artery.
- Antiplatelet therapy is commonly used to prevent thrombotic events 2, 3.
- Medical management of asymptomatic cases allows for the study of the natural history of the disease 5.
Surgical Intervention
Surgical intervention is typically reserved for symptomatic FMD of the internal carotid artery.
- Surgical intraluminal dilatation, either isolated or combined with reconstructive techniques, is a safe and durable operation that can relieve symptoms 5.
- The benefits of repair are long-lasting, and surgical intervention should be offered to patients with symptomatic FMD carotid lesions 5.
- Surgical treatment may also be necessary for complex cases, such as those with associated aneurysms or dissections 4, 5.
Follow-up and Outcomes
Long-term follow-up is essential to monitor the progression of FMD and the effectiveness of treatment.