Carotid Artery Disease - CAD

The carotid arteries are the main blood vessels to the brain. These arteries can develop a build-up of plaque caused by atherosclerosis, or “hardening of the arteries”. When plaque in the carotid arteries (arrow) becomes very severe, a stroke can occur. This process is similar to the build up of plaque in the arteries to the heart that causes heart attacks. Since strokes occur in the brain, many doctors today refer to strokes as “brain attacks”.

Almost everyone knows someone who has had a stroke, and it's usually not good. A stroke can be fatal, but even people who survive a stroke may have paralyzed arms or legs, or may not be able to talk or eat normally. Many people recover from strokes, but it often takes a long time. There are some very encouraging new treatments for stroke today, but once a stroke has occurred there is some permanent brain damage.

• Our goal today should be to prevent a stroke before it happens
• If you have severe carotid artery disease and have a high risk for stroke, surgery - a carotid endarterectomy - can be done to prevent that stroke !
• It has been shown in numerous studies that, in these cases, surgery is better than any medical treatment for preventing a stroke !

It 's not possible to prevent all strokes. But more than half of all strokes in the US may be due to carotid artery disease. Severe carotid artery disease can be easily detected with a simple ultrasound examination that takes less than 30 minutes! You could nap through this test and it might save your life !

Common Questions About Stroke?

Stroke - It's a matter of life and limb!

Stroke is the 3rd leading cause of death in the US today. Even stroke survivors are frequently left with permanent physical and mental disabilities. More than $70 billion are spent each year in this country to care for stroke and stroke survivors. The only way to save these lives, save the function of these limbs, and save the billions of dollars spent is to prevent stroke!

Stroke - What is it ?
A stroke occurs when part of the brain is damaged - not by trauma, but by vascular problems.

• In some forms of stroke the brain damage is caused by bleeding – these are called “hemorrhagic strokes” and the hemorrhage (bleeding) may be caused by severe high blood pressure, or aneurysms of the smaller arteries within the brain
  
  
• Most strokes (80% or more) happen because the circulation to part of the brain is cut off and brain cells die. These strokes are called “ischemic strokes”, and most of these are caused by blockages in the carotid arteries.

When atherosclerotic plaque builds up in the carotid artery it produces a progressively more severe blockage (“stenosis”) which ultimately results in reduced blood flow through that vessel to the brain. Severely reduced flow may cause a stroke, but we think most strokes are actually due to small bits of plaque, or bits of clot that form around the plaque washing up into the microscopic vessels that supply oxygen directly to brain cells. This helps explain why many patients have little “mini-strokes” (we call them TIA’s) as a warning sign before they suffer a real stroke. Because these mini-strokes, or TIA’s resolve completely (often within minutes) many folks don’t tell their doctors. Then when a stroke finally occurs, the damage is already done!

Warning Signs for Stroke

• Sudden weakness or clumsiness of your hand
• Sudden weakness or paralysis of an arm and/or leg
• Unexplained slurring of your speech or garbled talk
• Sudden blurriness or even blindness in one eye
• Severe dizziness or near black-out
• Severe unremitting headache

If these things happen to you, or if they have happened recently, see your doctor and report them. A simple ultrasound scan can quickly and easily tell if you have severe carotid disease. If these things happen to you and you cannot contact your own doctor, seek emergency medical attention – you may be able to prevent your own stroke !

Who’s at risk?

Those people with risk factors for:

• Atherosclerosis
• Hypertension (high blood pressure)
• Diabetes
• Smokers
• High cholesterol levels
• People with a family history of stroke
• People who have had a prior stroke
• People with irregular hearbeats, particularly atrial fibrillation
• People who have required treatments for severe circulatory problems in other areas
• Heart bypass
• Leg bypass

Prevention

Most people with carotid artery disease don’t need surgery. A little plaque in the carotid arteries is normal for most older Americans - it’s part of the aging process. We get more concerned when plaques grow to the point where they cause a 60-70% blockage or more, or if they cause symptoms like TIA’s. Obviously, if you have a little bit of plaque the goal is to prevent it from becoming worse! This is where medical treatments and your own personal efforts can have a tremendous effect. Here are some of the things that can be done to reduce your risks of getting worse:

• If you smoke, stop smoking!
  
  
• Achieve good blood pressure control
  • If you have hypertension (high blood pressure), follow your doctor’s orders for treatment
    
    
• Get regular exercise
  • It’s good for your entire cardiovascular system and your metabolism
    
    
• Control your blood cholesterol
  • If your doctor discovers that your cholesterol is high, then lowering it will be beneficial. This can often be done simply by changing what you eat, but there are also excellent medications that can really help. Studies have shown that lowering cholesterol levels can significantly reduce the risks of heart attacks and strokes

Treatment

People with severe blockages in their carotid arteries should be considered for surgical treatment – called carotid endarterectomy. This procedure removes the plaque from inside the artery wall and restores the artery to normal. We can see from ultrasound exams that are done after surgery, that the plaque is gone and the blood flow is back to normal. Carotid endarterectomy is so successful because the plaque in the carotid artery is limited to a very small area in the mid-portion of the artery in the neck. This allows surgery to be done through a small incision, in many cases under local anesthesia. When everything goes well, most patients can go home the morning after surgery. Recovery from surgery is usually rapid and people can quickly resume their normal activities without any restrictions.

Of course no surgery can be done without risks. One of the most serious risks of carotid endarterectomy is that a stroke can happen during the procedure. While it seems odd that a procedure being done to prevent a stroke could actually cause one, it’s really not so hard to understand. We know we are working on a plaque that carries a dangerous risk of stroke – and that stroke could occur anytime, even during the procedure itself. What we know for certain is that the real risk is if nothing is done. Numerous large, scientific studies in the US and Europe have confirmed that for patients with severe carotid artery disease, carotid endarterectomy was better at preventing a stroke than the best medical treatments doctors could provide. Patients receiving medical treatment alone were two to three times more likely to have a stroke than those who had surgery.

Recently, doctors specializing in the treatment of vascular problems have begun to investigate the use of balloon angioplasty and stent placement in the carotid arteries. Almost everyone today has heard of balloon procedures that have been used routinely in the coronary arteries to the heart or in the circulation to the legs, but their use in the carotid arteries has been investigational. Early results of angioplasty and stents for treatment of severe carotid disease was not as good as surgery, but significant changes have been made in the procedures and the equipment that may make these treatments safer. Studies comparing stent procedures to carotid endarterectomy are now in progress. If you or a family member have severe carotid disease and have had TIA’s, you may be asked to participate in one of these studies. Certainly if we found that the stent procedure was as successful and durable as surgery this would be a major advancement.

What does a Vascular surgeon do?

– Carotid Artery Disease

Vascular surgeons have pioneered and refined ultrasound scanning for the diagnosis of carotid artery disease. The severity of a blockage can be determined without any risk or discomfort to the patient. In many cases this can eliminate the need for costlier and more risky examinations like arteriograms (catheterization procedures).

Vascular surgeons pioneered and refined carotid endarterectomy for the treatment of severe carotid artery disease. We recognized right away that this procedure reduced the risk of having a stroke, but for decades, many physicians remained skeptical. This procedure has been tested, and retested compared to all medical treatments! Now even the most skeptical would have to admit that it has been successful.

Vascular surgeons have proven that their surgery is of life-long benefit. Ultrasound scans of the carotid arteries are performed routinely after surgery. More than 90% of patients are free from stroke and have normal carotid arteries for the rest of their lives.

Vascular surgeons are now testing newer treatments like angioplasty and stent placement for treatment of severe carotid disease, to see if it will be a successful as current surgical treatments.

If you or any of your family members have carotid artery disease and are having symptoms, or if your think you might be at risk for having a stroke, for any of the reasons listed above…see your doctor and ask them.

If you’d like to get the opinion of a Vascular Surgeon, click here to find a Vascular Surgeon near you.