Vascular Surgery: Carotid Artery Disease

Stroke is the third most common cause of death in the United States, with a rate that is increasing as the population ages. The carotid and vertebral arteries are the blood vessels that carry blood to the brain. These arteries can develop a build-up of plaque with “hardening of the arteries.” With continued plaque buildup, severe narrowing of the carotid artery can occur, reducing blood flow to the brain. Portions of the plaque can also break off and travel to the brain (embolism). When either a severe narrowing or embolism occurs, a transient ischemic attack (TIA) or stroke may develop. A TIA is a temporary loss of brain function, causing symptoms which return to normal in a short time. A stroke causes permanent loss of brain matter, which may result in loss of normal body function.

• Who is at risk?
• What are the symptoms?
• How are carotid diseases diagnosed?
• What is the surgical treatment?

Who is at risk?

Carotid artery plaque

People who are at risk for a stroke have atherosclerosis (hardening of the artery), high blood pressure, smokers, high cholesterol, diabetes, have had a prior stroke, have a family history of a stroke, a history of bypass surgery, or an irregular heart beat.

Warning signs of a stroke are sudden weakness or paralysis of the arms or legs, slurred speech or difficulty speaking, sudden loss of vision in one eye, dizziness or near-black-out, or severe headaches which don’t go away. If you have any of these signs, please call your doctor or go to the nearest emergency room.

Most people with carotid artery disease do not need surgery. We get concerned when people have had a stroke or have a narrowing of the carotid artery that is more than 50%.

How to reduce your risk:

• If you smoke, stop smoking.
  
• Manage medical conditions like:
• High blood pressure
• Diabetes
• Heart disease
• High cholesterol
• Exercise regularly
  
• Eat a healthy diet

What are the symptoms?

Transient Ischemic Attacks (TIA’s)

TIA’s are also called “mini-strokes.” These are temporary neurologic events which last from several seconds to a few hours. The symptoms that occur, temporary blindness or weakness in the arms or legs, can last no longer than 24 hours. After that period of time it is considered a stroke.

A TIA is a warning sign of a stroke and a thorough physical exam and tests are necessary to prevent a stroke. If you have any of these symptoms, please contact your doctor or go to the nearest emergency room.

Vertebrobasilar Insufficiency

This is a condition in which the patient may become unsteady when standing, have visual changes or have weakness or numbness and tingling on both sides of the body. This is primarily due to reduced blood flow through the vertebral arteries and is more likely to occur if there are also blockages in the carotid arteries.

Some patients have a buildup of plaque (atherosclerosis) which can break off and go to the brain and cause a stroke.

If you have any of these symptoms, please contact your doctor or go to the nearest emergency room.

Stroke

This is when the neurologic deficits, such as weakness or paralysis, are permanent. Here a part of the brain is damaged. A few patients may benefit from surgery to clean out the carotid arteries, but most patients are treated with medical therapy and intense physical therapy and rehabilitation.

The main treatment of a stroke is its prevention.

How are carotid diseases diagnosed?

Carotid Angiogram

A carotid angiogram is a procedure performed by a radiologist or a vascular surgeon. It is a test which “maps out” the arteries that carry blood to the brain—the carotid and the vertebral arteries. It helps to identify blockages in these arteries and helps the vascular surgeon plan treatment. An angiogram is an outpatient procedure that is done in the hospital. A tiny catheter is passed through the groin (or arm) and a “dye” is injected which fills the vessels in the neck and the brain, and x-rays are taken.

Once the test is completed, pressure is applied to the groin (or arm) to prevent bleeding. You will need to lay flat and keep your leg straight for a few hours.

Angiograms are safe. There is, however, a small risk of stroke, bleeding and allergic reaction to the dye.

Call your doctor if you notice bleeding, pain, or lightheadedness, or if you notice a lump at the site of the test.

Carotid Magnetic Resonance Angiogram (MRA)

MRA is a non-invasive test that is done in the hospital. It is an outpatient procedure which takes images of the blood vessels which carry blood to the brain (carotid and vertebral arteries) without the use of x-rays. This test is similar to an angiogram, but no catheters or guide wires are introduced into the blood vessels; only an intravenous (IV) line is required.

Some persons are claustrophobic (afraid of being in an enclosed space) or have a pacemaker. This test can be used under these conditions.

Carotid Bruits

A bruit is a sound that can be heard with a stethoscope by your doctor. This sound is made by blood as it passes through a narrowing in the carotid artery.

Most patients with a bruit do not need treatment, but some patients will have a stroke. Your doctor will recommend tests to determine your individual risk of having a stroke and discuss your treatment.

Carotid Duplex

If a sound (bruit) is heard with a stethoscope applied to the neck, or if you have symptoms of a stroke, a carotid duplex is a quick, safe and reliable test to evaluate the carotid and vertebral arteries.

Sound waves (ultrasound) are used to visualize these vessels and evaluate them for blockages, flow disturbances, and ulcers. Images are viewed on a monitor and can be recorded. The results of this test will help your doctor determine the appropriate treatment for your condition.

Head CT Scan

This test gives us pictures of the brain and helps us to determine whether you have had a stroke. It will show us areas of bleeding or infarcted (dying) brain tissue. This will allow your doctor to determine the appropriate treatment and tests that you require.

A “dye” (contrast) may be injected into your intravenous (IV) fluid which also helps determine if you have any injury to your brain.

Please inform your doctor if you are allergic to dye.

What is the surgical treatment?

Carotid Endarterectomy (Carotid Artery Surgery)

Carotid endarterectomy is a surgery to reopen a narrowed carotid artery. If you have symptoms of a stroke or if the carotid narrowing is more than 60-70%, you may need surgery.

After anesthesia has started, an incision is made in the neck on the affected side. The carotid artery is opened and the plaque (narrowing) is removed. The artery is then closed with sutures. Sometimes a technique is used to widen the artery if your surgeon thinks that the narrowing may recur.

Your brain will be monitored during surgery and blood flow is maintained to prevent a stroke. Despite this, there is a 1-2% chance that you may have a stroke. Many different procedures and monitors are used during surgery to reduce your risk of having a stroke.

Pre-Surgical Information: Carotid Artery Surgery will help you prepare for your surgical procedure. The average hospital stay is 1-2 days.

Post-Surgical Instructions: Carotid Artery Surgery, will give you some indication of the typical post surgical course.

Carotid Angioplasty

Carotid angioplasty and stenting is a new treatment modality which is currently offered to high risk patients—i.e., redo carotid surgery, high carotid blockages, multiple medical problems.

This new technique is currently in its early development. The procedure is performed in the x-ray department. A catheter is passed through the artery in the groin and advanced to the blockage in the artery, where a balloon is used to open up the blockage. A stent (a small metallic cylinder) is then placed in the same area to help keep the artery open. There is no surgical invasion and patients are able to go home the next day. However, this procedure is still in its early development and may not be appropriate for you.