CAROTID ARTERY DISEASE
WHAT IS CAROTID ARTERY DISEASE?
Your arteries are responsible for delivering oxygen-rich blood from your heart to other parts of your body. Your carotid arteries are two main arteries that carry blood from your heart, up through your neck, to your brain.
Healthy carotid arteries are smooth and unobstructed, allowing blood to flow freely to the brain and provide oxygen, glucose, and other nutrients that your brain cells need. Typically with age, the carotid arteries build up plaque, a sticky substance made up mostly of fat and cholesterol. Plaque narrows the passageway within the arteries and causes them to become stiff. Carotid artery disease results when the carotid arteries become too narrow or obstructed and limit the blood flow to the brain.
Strokes result either from obstruction of blood flow to the brain by the plaque or when bits of plaque and clots break off from the plaque and flow to the brain. If left untreated, carotid artery disease may lead to stroke. Depending on its severity, a stroke can be fatal. In fact, strokes are the third leading cause of death in Ireland and the leading cause of permanent disability in older adults.
CAUSES AND RISK FACTORS
- Age (45years and older)
- Hypertension (high blood pressure)
- Diabetes
- Smoking
- High cholesterol
- Obesity
- Lack of exercise
- Family history of atherosclerosis (hardening of the arteries) and/or stroke
- Irregular heartbeat, particularly atrial fibrillation (a diagnosed condition where the heart chambers quiver and beat ineffectively)
SYMPTOMS AND WARNING SIGNS
There may be no symptoms in the early stages of carotid artery disease, and stroke could be the first sign of the condition.
Stroke, however, can have warning signs, referred to as mini-strokes or transient ischemic attacks. Mini-stroke symptoms are usually temporary, lasting a few minutes to a few hours, and should be treated as serious medical emergencies requiring immediate treatment because they are strong predictors of future stoke.
DIAGNOSIS
Diagnosis of carotid disease begins with a careful medical history, including risk factors and physical exam.
Doppler/Duplex Ultrasound: A technologist uses sound waves to make images of your carotid arteries (ultrasound). During the test a special ultrasound probe is gently pressed against your neck.
An image then forms on a monitor the result shows how severe the narrowing is.
Other Imaging Tests Patients also have brain imaging performed such as CT scan, prior to surgery, that can show damage from a past stroke.
Some patients will have get an injection of dye (contrast) during this CT scan to get a closer look at their carotid arteries. If dye is used it is called a CT Angiogram.
TREATMENTS
CAROTID ARTERY DISEASE
Vascular surgeons are the only physicians who can perform all the treatment options available, including medical management, carotid endarterectomy and minimally invasive endovascular angioplasty and stent procedures.
Only when you see a vascular surgeon who offers all treatment modalities will you be assured of receiving the care that is most appropriate to your condition.
Risk Factor Control
- Stop Smoking
- Low Fat Diet
- Exercise
- Control of High blood Pressure and Diabetes
Medical Treatment
A combination of medication, called the ‘Magic Bullet’ is used to thin the blood, reduce the build-up of plaque and lower blood pressure. This includes a combination of blood thinning agents, statins and anti-hypertensive medications.
WHEN IS INTERVENTION REQUIRED
Whether you need intervention or not depends on your symptoms and how severely narrowed your carotid artery is.
In many cases patients are given best medical treatment and followed up on a regular basis.
If you have mild narrowing but have had TIA’s you may need surgery.
Even if you haven’t had any TIA symptoms, your risk of having a stroke may still be high if one of your arteries is severely narrowed. In that case intervention may also be needed.
CAROTID ENDARTERECTOMY
The gold standard and most successful treatment for carotid artery disease is carotid endarterectomy.
During a carotid endarterectomy an incision is made along the side of the neck and the carotid artery is then opened and the atherosclerosis is removed. The artery is repaired with either sutures or a small material patch. This is done using general anaesthesia.. Most patients are discharged from the hospital within 48 hours of undergoing the operation.
CAROTID ANGIOPLASTY AND STENTING TECHNIQUE (CAST)
Carotid angioplasty and stenting is a relatively new procedure in the treatment of carotid artery disease in suitable patients.
Its implementation is limited to patients who have received radiotherapy to their neck in the past, or have re-narrowing (stenosis) of a carotid artery that was previously treated.
In carotid angioplasty, a balloon is attached to a catheter, a long tube, which is inserted in the groin artery and threaded through the arteries to the narrowed carotid artery. The balloon at the end of the catheter is inflated to open the narrowed area, and a metal stent, which is a kind of wire mesh tube, is left in place to keep the artery from narrowing again.
Patients are awake during the procedure, and are usually discharged from the hospital within 24 hours.
PROTECTION OF YOUR GRAFT
If you have a carotid patch or endovascular stent in place, inform the relevant doctor or dentist if you are having further surgery or any invasive procedure, such as an angiogram.
You may need ‘prophylactic’ antibiotics to protect you from infection.
SCREENING PROGRAMME
Stroke is the third most common cause of death in Ireland and is responsible for one in ten of all deaths.
Treatment of stroke, once it has occurred is generally unsuccessful. Over 80% of all strokes are Ischaemic and the optimal treatment for ischaemic stroke is primary prevention.
Carotid Artery Disease is easily and accurately identified using ultrasound scanning. Once identified treatment of predisposing conditions such as carotid artery disease can reduce the incidence of stroke by up to 50%.
REFERENCES
- Lally C, Hynes N, Sultan S. Preclinical Medical Device Testing and the Potential of Non-Invasive Imaging Carotid Artery Intervention In High-risk Patients: Vascular 2008 16 (2) S103
- Hynes N, Sultan S. Carotid Artery Stenting (CAS) Under Neuro-protection, Carotid Endarterectomy (CEA) And Best Medical Therapy (BMT) for symptomatic patients with low Grey Scale Median (GSM). Vascular 2008 16 (2) S108:
- Sultan S. Contemporary Trends in Carotid Intervention: the 21st Century Approach to Carotid Endarterectomy, Carotid Artery Stenting under Neuro Protection and Optimal Medical Treatment Vascular 2008 16 (2) S108:
- Sultan S. Carotid stump syndrome. A case report and literature review. Int Angiol. 2004 Sep;23(3):284-7. Review. PMID: 15765045