Canada Vascular

Cerebrovascular Disease

Background

How Can Carotid Artery Disease Be Diagnosed?

Treatment Options

How Can I Get Screened & Treated for Cerebrovascular Disease?

Common Questions & Answers

Bibliography

 

 


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.

Fig. 1 Fig. 2

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.

Fig. 3 Fig. 4 Fig. 5
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