Carotid Artery Disease


Carotid artery disease is the narrowing of the carotid arteries, the main arteries located on the sides of your neck. These arteries supply blood flow directly to the brain.   A blockage consisting of an atherosclerotic plaque can develop in the artery.  This blockage can not only narrow the channel for blood to flow through but can also cause turbulence and small clots to form on the plaque surface.  These small clots and bits of plaque can “break off” into the bloodstream and be carried away – up to the brain and cause a stroke or mini-stroke. A stroke is a sudden change in neurological functioning that results in paralysis, weakness, blindness, numbness or difficulty with speech.

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Common Risk Factors

  • Age
  • Smoking
  • Coronary artery disease (history of heart attacks)
  • High blood pressure
  • High cholesterol
  • Diabetes
  • Obesity
  • Kidney failure
  • History of radiation to the neck (i.e. treatment of neck cancer)

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Symptoms

Symptoms of carotid artery disease consist of stroke or mini-stroke symptoms.  Because of the sudden blockage of blood flow to an artery in the brain the nerve cells in the brain stop working properly.  This can cause sudden:

  • Paralysis of an arm or leg (usually on one side of the body)
  • Weakness of an arm or leg
  • Numbness
  • Blindness in one eye
  • One-sided facial droop
  • Slurring of speech or difficulty speaking

A mini-stroke, or transient ischemic attack (TIA), consists of the same symptoms above but, unlike a stroke, usually passes within a few minutes.  Both a stroke and mini-stroke are medical emergencies and should be dealt with by calling 911 or your local EMS for immediate transport to a hospital.

Most of the time patients may not have any symptoms of carotid artery disease at all. However, during a physical exam, a doctor may hear a “bruit,” an abnormal “whooshing” sound, through the stethoscope when listening to your neck.  Other conditions such as dizziness, fainting spells, or vertigo are not usually directly associated with carotid artery disease but may lead to tests that discover its presence.

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Tests and Diagnosis:

Ultrasound

This is usually the first line test to evaluate for carotid artery disease.  It is a painless, non-invasive test that can be done in your surgeon’s office in less than 30 minutes.  It involves placing an ultrasound probe on your neck and obtaining images of your arteries and measuring the blood flow.

CT Angiography / MR Angiography

A CT scan or MRI that is focused on evaluating the arteries of your neck may sometimes be needed to better image the blockages and surrounding normal tissues.  This test may also be used to confirm the findings of an ultrasound if surgery is anticipated.  These tests have the added advantage of possibly identifying another cause for symptoms that might not clearly be from carotid artery disease.  These tests involve injecting a contrast agent into your veins.

Angiography

Angiography may be used to image the carotid arteries, usually after the above less-invasive tests have been performed, in order to obtain finer detail about the carotid arteries.  This may be because of disagreement between other tests or as part of a planned treatment such as stenting (see Treatment options). This involves injecting contrast agents (“dye”) through a catheter into an artery.  Typically the patient is given a mild sedative before and during the procedure and the area over the artery, usually in the groin or elbow, is injected with a local anesthetic.  Injecting the dye into the artery or vein creates an image called an “angiogram” that provides the detail necessary to plan out the proper treatment for you.

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Treatment options

Treatment of carotid artery disease depends on several factors, specifically whether or not the blockage is causing stroke or mini-stroke symptoms, how severe the blockage is, and a patient’s overall medical condition.   Regardless of these considerations there are medications and other steps that should be used to treat carotid artery disease whether or not surgery is planned.  These include anti-clotting medications (such as aspirin), anti-hypertensive medications, cholesterol lowering medications, and steps to stop smoking.

Patients who have symptoms of stroke or mini-stroke and are found to have a blockage over 60% should be considered for surgery.  Some patients with blockages less than 60% but who are found to have very complex or “vulnerable to rupture” plaques in the carotid arteries may be considered for surgery as well.  Patients who have no symptoms but are found to have blockages over 70% are typically considered for surgery.  The rationale behind recommending surgery is to prevent stroke.  Patients who have had a stroke or mini-stroke are at high risk for a second event.  The risk for patients with no symptoms is primarily based on the observation that their risk for stroke increases as the blockage worsens.  When this risk of stroke outweighs the risks of surgery the recommendation to operate is generally made.

Many patients are found to have blockages that do not meet criteria to be repaired – it is imperative that these patients be treated to control the risk factors that lead to carotid artery disease and that they have regular, scheduled follow-up ultrasounds to track the effect of their blockage.  A significant group of patients will experience worsening of the blockage and eventually require surgery.   Surgical treatment consists of two primary options: endarterectomy and stenting.

Carotid Endarterectomy
Carotid endarterectomy (CEA) has been used since the 1950’s and is one of the most studied and evaluated procedures in history.  Essentially the carotid artery is opened up and the plaque is removed from the inside of the artery.  The hole is then patched closed again.  This is usually done under a general anesthetic although it can be done with local anesthesia as well.  A small incision is made on the side of the neck, and patients will generally be able to go home the following day.

Carotid Angioplasty & Stenting
Carotid angioplasty and stenting (CAS) is a recently developed technique for treating carotid artery disease.  In essence a stent is placed across the blockage with the goal of restoring the normal blood flow channel and “scaffolding” the plaque in place in order to prevent parts of it from travelling to the brain.  Unlike an endarterectomy the plaque is left in place.  Much like other angioplasty procedures it is minimally invasive and only requires a puncture site in a groin artery.  Most patients will go home the following day.  Because it is a relatively new procedure it is still being intensely studied and is currently available as an option to patients with very blocked arteries who have had a stroke or mini-stroke and, because of other severe medical problems, are considered “high-risk” for surgery.

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FAQs

What is carotid stenosis?
Plaque building in the major arteries in the neck that supply blood flow to your brain.

Is carotid stenosis a serious condition?
Yes, plaque formation can lead to partial or complete of block of blood flow and cause stroke, mini strokes, light headedness, or even passing out.

What can be done for carotid stenosis?
Depending on severity of blockage, treatments range from medicines, angioplasty/stenting or surgery to clean out the plaque.

How dangerous is surgery for carotid stenosis?
Overall, carotid surgery is a safe procedure requiring only one night in the hospital.  The risk of stroke, death, or major complication is 2-3 chances out of 100 (2% – 3%).

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Helpful Links

Please visit these websites for detailed information directed to patients and their families:

http://vascularweb.org/vascularhealth/pages/carotidarterydisease,stroke,transientischemicattacks(TIAS).aspx

http://www.webmd.com/heart-disease/carotid-artery-disease-causes-symptoms-tests-and-treatment

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