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Of the 600,000 strokes that occur each year in the USA, it is estimated that 30-40%
are caused by plaque in the carotid artery. This means that if the carotid artery
plaque is discovered before a stroke occurs, the potential exists to prevent as
many as 200,000 strokes annually.
Plaque accumulation in the carotid artery can be associated with symptoms or it
may be silent ("asymptomatic"). Stroke may occur when a piece of plaque breaks free
and travels to the brain or if the plaque in the carotid artery becomes so thick
that it shuts down blood flow completely. Approximately 50% of people who suffer
a stroke will die from the event and about 50% of the survivors have some permanent
neurological deficit such as paralysis or inability to speak.
Another event that can occur due to plaque in the carotid arteries is a Transient
Ischemic Attack (TIA). This is sometimes called a "mini stroke" but actually it
is not a stroke.
Temporary weakness or numbness of an arm or leg (or both the arm and the leg on
the same side of the body)
Temporary speech difficulty
Transient loss of vision in one eye (called transient monocular blindness or TMB)
When a person who has experienced a TIA is found on ultrasound exam to have a critical
stenosis of the carotid artery, the risk of a stroke is thought to be about 30%
during the next six months after the occurrence of the TIA. Surgery is recognized
as the best option in such patients according to a widely accepted national prospective
randomized study of this subject called the NASCET Trial.
Stenosis of the carotid artery is frequently silent and the plaque accumulation
is discovered only because a physician has recommended an ultrasound examination
of the neck as a "screening procedure". Patients who should be screened for carotid
plaque are those with:
Coronary artery disease
Previous Myocardial Infarction
Peripheral vascular disease
Family history of stroke
When plaque accumulation in the carotid artery has narrowed the artery by more than
80%, many vascular specialists will recommend that the plaque be removed. The advisability
of surgery for this group of patients was proven by another prospective, randomized,
national study called the ACAS Study. In most cases, the safest and most effective
method for dealing with carotid artery plaque is by an operation called a carotid
The decision to recommend surgery for any individual patient should be considered
on a case by case basis by the physicians and surgeons who are treating that individual
patient. Many factors should be considered in the decision making process. Not all
patients need surgery. Some patients are best treated with medical management including
statin therapy and anti-platelet therapy.
This operation is performed via a small incision on the side of the neck. The artery
is opened and the plaque is removed. Frequently, the vascular surgeon will enlarge
the artery by sewing a patch of vein or artificial material onto the artery after
the plaque is removed. The operation is safe, extremely effective in preventing
stroke and quite durable over the long-term in preventing stroke.
The success of this operation has been shown to be very dependent upon the experience
of the surgeon. Results of operation vary from complication rates (meaning stroke
during the operation itself) of 1-2% to as high as 10% with high volume surgeons
having lower stroke rates than surgeons with a low volume of carotid surgery. In
my own series of carotid operations in more than 1000 patients over a period of
more than 20 years, the risk of stroke has been less than 1%. The average patient
undergoing carotid endarterectomy is able to leave the hospital in one day. Recovery
at home is rapid. Patients rarely have significant pain. Recurrence rates of carotid
stenosis are very low-particularly if a vein patch is used to enlarge the carotid
artery after the plaque is removed (see Video #2, Video #12).
Balloon angioplasty has been used in many arteries of the body including the femoral
and iliac arteries of the leg and the coronary arteries of the heart. It was only
a matter of time before it was tried in the carotid arteries. The procedure remains
under investigation at this point and some of the surgeons who were initially enthusiastic
about this procedure have had this enthusiasm tempered by less than satisfactory
outcomes. It must be remembered that the balloon angioplasty and stent procedure
is designed to crush plaque-NOT to remove it. Many strokes are considered to be
caused by fragments of carotid artery plaque traveling from the neck to the brain.
It would be expected that crushing a plaque with a balloon angioplasty and stent
technique could lead to more fragments than the complete removal of a plaque from
within the artery using meticulous surgical technique. Whereas a small piece of
plaque traveling downstream from an angioplasty site may be easily tolerated in
the leg or even the heart muscle, the consequences of such plaque fragmentation
in the brain can be devastating.
The standard carotid endarterectomy operation has been perfected to the point that
most surgeons are reluctant to allow their patients to undergo the less successful
carotid angioplasty/stenting procedure. Some vascular surgeons who routinely advise
angioplasty/stenting of arteries in the abdomen, legs and heart will not advise
carotid angioplasty/stenting. At this point in time carotid angioplasty/stenting
is still an investigational procedure that must be compared with the carefully studied
and clinically proven technique of carotid endarterectomy surgery. No long-term
follow-up studies are available to permit a comparison of the durability of carotid
angioplasty/stenting with carotid endarterectomy surgery.
A carotid artery dissection is a tear in the inner lining of the carotid artery that causes blood to flow between the layers of the artery wall. This reduces the size of the lumen of the artery and can reduce the amount of blood flowing to the brain. There is no bleeding into the neck with these tears because it occurs in the inner layer of the artery (there are three layers to each artery). A dissection can be caused by many things including direct trauma to the neck, twisting or hyperextending the neck, straining (as when lifting heavy weights), certain yoga positions, and chiropractic manipulations. A carotid artery dissection usually presents as pain in the neck, with or without headache. Often, but not always, there are neurologic symptoms consistent with a TIA or stroke. Most carotid artery dissections heal after treatment with anticoagulant medications such as heparin and warfarin ("Coumadin"). Surgery is rarely necessary. Although it has been tried, there is rarely a role for placing a stent into the carotid artery to treat a dissection. The diagnosis is established by studies such as carotid artery ultrasound, MRA (magnetic resonance angiogram), CTA (CT angiogram), or conventional angiography.