Cerebrovascular & Carotid
Artery Disease
Treatment Options
Conservative Treatment
Carotid Endarterectomy
Carotid Stenting
Preventing Cerebrovascular Disease
Conservative Treatment
If you do not require surgery, make sure you and your immediate
family members understand the warning signs of TIA. Follow
your physician's instructions for any prescribed medications,
such as aspirin, to thin your blood, or statins, to control
your blood lipid (fat) levels. It is also important to return
for any scheduled follow up tests because the carotid blockage
may worsen over time, even without warning symptoms.
Changing some lifestyle factors may limit the progression
of your carotid artery disease. The first step smokers should
take is to quit smoking. Other changes that can decrease
your risk of carotid artery disease include losing weight,
exercising regularly, and eating a diet low in saturated fats.
Carotid Artery Endarterectomy
What is carotid endarterectomy?
Carotid endarterectomy is an operation that removes the inner
lining of your carotid artery. This procedure eliminates
a substance called plaque from your artery.
As you age, plaque can build up in the walls of your arteries.
Cholesterol, calcium, and fibrous tissue make up this plaque.
As more plaque builds up, your arteries narrow and stiffen.
This process is called atherosclerosis, or hardening of the
arteries. Eventually, enough plaque builds up to reduce blood
flow through your carotid arteries, or cause irregularities
in the normally smooth inner walls of the arteries.
Your carotid arteries are located on each side of your neck
and extend from your aorta in your chest to the base of
your skull. These arteries supply blood to your brain.
Carotid artery disease is a serious issue because clots
can form on the plaque. Plaque or clots can also break
loose and travel to the brain. If a clot or plaque blocks
the blood flow to your brain, it can cause an ischemic
stroke, which can cause brain damage or death. If a clot
or plaque blocks a tiny artery in the brain, it may cause
a transient ischemic attack, also known as a mini-stroke.
To remove plaque in your carotid arteries and help prevent
a stroke, your physician may recommend a carotid endarterectomy.
Carotid endarterectomy is one of the most commonly performed
vascular operations, and is a safe and long-lasting treatment.
To read the patient guideline, click here
How do I prepare?
Your physician or vascular surgeon will give you the instructions
you need to follow before the surgery, such as fasting.
Before your vascular surgeon performs a carotid endarterectomy,
he or she may want to determine how much plaque has built
up in your arteries. The most common test used for this purpose
is duplex ultrasound. Duplex ultrasound uses high-frequency
sound waves to show your blood vessels and measure how fast
your blood flows. Other tests your vascular surgeon may use
include:
- Angiography (or arteriography)
- Magnetic resonance angiography
(MRA);
- Computed tomography (CT) scan
Am I eligible for carotid endarterectomy?
You are eligible for the procedure if you have severe narrowing
of your carotid arteries, especially if you are experiencing
transient ischemic attacks and are in reasonably good health
otherwise. You may be eligible, but at a relatively increased
risk, if you have:
- Had a large stroke without recovery
- Widespread cancer with a life expectancy of less than
2 years
- High blood pressure that has not been adequately
controlled by lifestyle changes or medications
- Unstable
angina (chest pains)
- Had a heart attack in the last 6 months
- Congestive heart
failure
- Signs of progressive brain disorders, such as Alzheimer's
disease
Am I at risk for complications during
a carotid endarterectomy?
Having had a stroke in the past increases your
chances for complications. Other factors that may
increase your chances for problems during a carotid
endarterectomy, in addition to those conditions
listed above, include:
- The presence of a serious disease, such as severe heart
or lung disease
- Plaque your surgeon cannot reach
through surgery
- Severe blockage in other blood vessels
that supply blood to your brain, such as the carotid artery
on the other side
- Having a new blockage in a previous carotid
endarterectomy on the same side
- Diabetes
What happens during a carotid endarterectomy?
You may either be put to sleep or, alternatively, your surgeon
can numb your neck area and keep you awake so you can communicate
with the surgeon during the operation. By staying awake,
you may help your physician monitor your brain's reaction
to the decreased blood supply. Once you are either asleep
or the area around your neck is completely numb, your surgeon
will shave the skin on your neck where he or she is going
to make an incision, to help prevent infections. Your surgeon
then makes the incision on one side of your neck to expose
your blocked carotid artery. Your surgeon then temporarily
clamps your carotid artery to stop blood from flowing through
it. During the procedure, your brain receives blood from
the carotid artery on the other side of your neck. Alternatively,
your surgeon can insert a shunt to detour the blood around
the artery that is being repaired.
After your surgeon clamps your carotid artery, he or she
makes an incision directly into the blocked section. Next,
your surgeon peels out the plaque deposit by removing the
inner lining of the diseased section of your artery containing
the plaque. After removing the plaque, your surgeon stitches
your artery, removes the clamps or the bypass, and stops
any bleeding. He or she then closes your neck incision
and the procedure is complete. Sometimes, a patch is used
to widen the artery. The procedure lasts for about 2 hours.
What can I expect after a carotid endarterectomy?
After surgery, you may stay in the hospital for 1 to 2 days.
During this time, your physician will monitor your progress.
Initially, during your recovery, you will receive fluid and
nutrients through a small, thin tube called an intravenous
(IV) catheter. Because the neck incision is so small, you
may not feel significant pain.
After you go home, your physician may recommend that you
avoid driving and limit physical activities for several weeks.
You can usually begin normal activities again several weeks
after the operation.
If you notice any change in brain function, severe headaches,
or swelling in your neck, you should contact your physician
immediately.
Are there any complications?
You may have complications following any surgical procedure.
A stroke is one possible complication following a carotid
endarterectomy. This risk is very low, ranging between 1
and 3 percent. Another unusual complication is the re-blockage
of the carotid artery, called restenosis that may occur later,
especially if you continue to smoke cigarettes. Temporary
nerve injury, where you might experience numbness in your
face or tongue, is another uncommon, but possible, complication.
This usually clears up in less than 1 month and usually doesn't
require any treatment.
What can I do to stay healthy?
Although a carotid endarterectomy may reduce your risk of
stroke, it does not stop plaque from building up. To prevent
hardening of the arteries from occurring again, you should
consider the following changes:
- Eat foods low in saturated fat, cholesterol, and calories
- Exercise regularly, especially aerobic exercises such
as walking
- Maintain your ideal body weight
- Avoid smoking
- Discuss cholesterol lowering medications and
antiplatelet therapy with your physician
Carotid Artery Stenting
What is carotid artery stenting?
Carotid artery stenting is a procedure in which your vascular
surgeon inserts a slender, metal-mesh tube, called a stent,
which expands inside your carotid artery to increase blood
flow in areas blocked by plaque.
Hardening of the arteries, also known as atherosclerosis,
can cause the build up of plaque. In hardening of the arteries,
plaque builds up in the walls of your arteries as you age.
Cholesterol, calcium, and fibrous tissue make up the plaque.
As more plaque builds up, your arteries can narrow and stiffen.
Eventually, enough plaque may build up to reduce blood flow
through your arteries, or cause blood clots or pieces of
the plaque to break away and block the arteries in the
brain beyond the plaque.
Your carotid arteries are located on each side of your neck
and extend from your aorta in your chest to the base of your
skull. These arteries supply blood to your brain. You have
two carotid arteries on each side, the external and the internal.
The external supplies blood to your face and scalp. Your
internal carotid artery is more important because it supplies
blood to the brain.
When plaque builds up and reduces blood flow in your carotid
arteries, you have carotid artery disease. This is a serious
issue because clots can form on the plaque and block the
blood flow to your brain. If a clot or plaque blocks the
blood flow to your brain, it can cause an ischemic stroke,
which can cause brain damage or death. An ischemic stroke
is a stroke that occurs because there is a lack of blood
flow to cells in the brain. Another problem that the plaque
can cause is an arterial embolism. This occurs when a small
piece of plaque or a blood clot breaks away from the site
where it formed and blocks another artery downstream. If
a clot blocks a tiny artery in the brain, it may cause a
transient ischemic attack, also known as a mini-stroke.
When your physician wants to treat a blocked carotid artery,
he or she may recommend that you have a stent inserted as
an alternative to surgical removal of the plaque, known as
carotid endarterectomy. During the carotid stenting procedure,
your physician inserts a stent into your carotid artery after
performing angioplasty. Angioplasty uses a balloon inflated
in the narrowed part of the artery to flatten the plaque
and open the artery. The stent holds the artery open by holding
back the flattened plaque like scaffolding.
How do I prepare?
Your physician may give you specific instructions to follow
before the procedure, such as fasting. You should always
inform your physician about any medications that you are
taking.
In most cases, your physician will instruct you take aspirin
and a prescription medication that prevents clots for 3 to
5 days before the procedure. Your physician may also order
a duplex ultrasound, a computed tomography (CT) scan, an
angiogram, or magnetic resonance imaging (MRI) to evaluate
the degree of blockage in your carotid artery.
Am I a candidate for carotid stenting?
You may be a candidate for the procedure if you are considered
high risk for carotid endarterectomy, if your carotid artery
is significantly narrowed (usually by more than 60 percent),
and if you have had symptoms of a mini stroke or stroke.
If you have no symptoms, you may also be a candidate if your
carotid artery is severely narrowed (more than 80%) and you
are considered high risk for carotid endarterectomy. You
may also be a candidate if you have developed a new narrowing
after previous carotid surgery.
You may not be a candidate if you have one or more of the
following:
- A life expectancy shorter than 2 years
- An irregular heart
rhythm
- An allergy to any of the medications used in the
procedure
- Bleeding in your brain within the last 2 months
- Complete
obstruction of the carotid artery
Am I at risk for complications during
carotid stenting?
Factors that increase your chance for having
complications during carotid stenting include:
- High blood pressure
- An allergy to contrast dye;
- Hardened and long narrowing
of the carotid artery
- Sharp bends or other difficult anatomies
in the carotid arteries
- Irregular-looking plaque
- Significant plaque or atherosclerosis
of the aorta near the beginning of the carotid artery
- An
age more than 80 years
- Extensive blockages in the arm and
leg arteries
What happens during carotid stenting?
The procedure usually takes place in an angiography suite
or catheterization lab. Before the procedure begins, your physician
will connect you to a monitor that shows your heart rate
and blood pressure. Your physician may instruct you to
squeeze a small toy or ball so that he or she can monitor your
brain function. While some physicians may perform the procedure
under general anesthesia, in most instances, the procedure
is performed while you are awake and alert.
Your physician will give you medications such as heparin
to prevent clots, atropine to reduce the chances of your
heart slowing down, and a local anesthetic to numb the
catheter insertion area. Your physician may not give you
any other medications so you will be alert to follow instructions
during the procedure. Your physician then locates the narrow
areas in your arteries by injecting a dye into your arteries
and taking live x rays. The dye does not allow x rays to
pass through, so physicians can see your arteries and use
the live x rays to guide them to the blockage.
Before inserting the stent, your physician will usually perform
angioplasty. In angioplasty, your physician inserts a long,
thin tube called a catheter with an attached balloon into
a small incision or puncture over an artery in your arm or
groin. Your physician guides the catheter to the blockage
site in your carotid artery using live x ray imaging. You
will not feel the catheters as they move through your arteries
because there are no nerve endings inside your arteries.
At this point in the procedure, your physician may insert
a small balloon, basket, or filter called an embolic protection
device. This device helps to prevent strokes by catching
the clots or debris that may break away from the plaque during
the procedure.
At the blockage site, your physician inflates and deflates
the angioplasty balloon to flatten the plaque and widen the
space where the blood flows through. After the artery is
open, your physician then removes the catheter with the balloon
attached.
Using a different catheter, your physician guides a compressed
stent to the same area in your carotid artery. Once the stent
is in place, your physician releases it. The stent then expands
to fit the artery. In most cases, your physician then uses
a balloon catheter to further expand the stent.
Your physician then removes the stent-carrying catheter and
any embolic protection devices. Stents remain permanently
in your carotid artery. Because stents are made of stainless
steel or metal alloys, they resist rust.
Carotid stenting usually takes about 1-2 hours but may take
longer in some circumstances.
What can I expect after carotid stenting?
Immediately after the procedure, your physician applies pressure
to the insertion site for 15 to 30 minutes to allow it to
close and prevent bleeding. To close the incision, your physician
may use, instead, a cork-like closure device or stitches
that dissolve.
If your physician inserts the catheters and other instruments
through your femoral artery, your physician may instruct
you to stay in bed for the next several hours so that he
or she can watch for any complications, such as bleeding
from the puncture site.
Your physician may instruct you not to lift anything more
than about 5 to 10 pounds, after you return home, to avoid
any pressure on the incision. Your physician may also instruct
you not to take a bath for a few days (but showers are fine),
and to drink plenty of water to help flush the dye out of
your system.
Are there any complications?
Blockage by a clot or other debris in an artery in your brain,
called an embolism, is the most serious complication that
can occur after carotid stenting. This blockage can cause
a stroke. Another complication that may cause a stroke is
a blood clot forming along the stent. The re-blockage of
the carotid artery, called restenosis, is another possible
complication. The dye used for the angiogram can sometimes
cause damage to the kidneys, especially in people who already
have kidney trouble. Bleeding from the puncture site in the
groin or arm artery, called a hematoma or a false aneurysm,
can also occur, but this is unusual. Bruising at the puncture
site is common, however, and usually resolves with time.
What can I do to stay healthy?
Although carotid stenting opens your artery and keeps blood
flowing, it does not stop plaque from building up. To prevent
hardening of the arteries from occurring again, you should
consider the following changes:
- Eat more foods low in saturated fat, cholesterol, and
calories
- Exercise regularly, especially aerobic exercises
such as walking
- Maintain your ideal body weight
- Quit smoking
- Follow your physicians recommendations for
medications to control cholesterol and to thin the blood
Preventing Cerebrovascular Disease
How do I Prevent Cerebrovascular Disease?
Eat more foods low in saturated fat, cholesterol, and calories
- Exercise regularly, especially aerobic exercises such
as walking
- Maintain your ideal body weight
- Quit smoking
- Follow your physicians recommendations for
medications to control cholesterol and to thin the blood
Carotid Stent Case
Dr. S. Kundu BSc, MD, FRCPC, DABR, FASA
Dr. J.M. You MD, FRCPS
Clinical History
64 years old male presented with a 6 month history
of intermittent difficulty with speech, and
transient numbness every three to four days
and transient numbness in right hand. Carotid
Ultrasound, echocardiogram, ECG and bloodwork
were all negative. Patient referred to speech
pathologist and a psychiatrist. After three
months patient referred to a Neurologist
and a Computed Tomography Angiogram was performed.
Clinical Investigation
Computed Tomography Angiogram demonstrated a severe eccentric
Left Common Carotid Stennosis (Fig 1 & 2). Patient was referred
for Carotid Stenting as surgery was determined to be a difficult
option given the proximal location of the stennosis.
Materials and Methods
A Thoracic Aortogram demonstrated the origin of the
great arch vessels to be within normal limits. There
was a moderate to severe narrowing of the proximal Left
Common Carotid Artery (Fig 3). A left cerebral angiogram
was within normal limits Cannulation past the stennosis
was performed with a .035 Cook Roas Runner Hydrophilic
Wire, 5 French Cook DAV 100 cm catheter, and a 5 French
Cook Shuttle Sheath. A 6 mm Angioguard Cordis Distal
Protection Device was inserted in the proximal left internal
carotid artery. A 7 x 40 mm Cordis Precise Stent was
inserted at the site of the stennosis (Fig 4). A post
stent placement balloon dilation was performed with a
Cordis 6 x 20 mm Ameia balloon. Post balloon dilation,
the left common carotid artery appeared widely patent
(Fig 5 & 6). A left cerebral angiogram was within
normal limits. Case performed at Scarborough General
Hospital: General Campus.
Clinical Outcome
There was a complete resolution of the patient's symptoms
with no further episodes of speech difficulty or numbness.
Summary
Carotid stenting is a viable treatment alternative to
carotid endarterectomy in patients with proximal common
carotid artery lesions, operative risk factors, post-operative
restennosis, and high internal carotid artery lesions.
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