What is Carotid Artery Disease?

The carotid arteries are two major arteries in the neck that provide most of the blood flow to the brain. The pulse that you can feel at the base of your neck, just to the side of the trachea (windpipe) is blood flow in these arteries. Over time, the carotid arteries can develop atherosclerosis or “hardening of the arteries”. Atherosclerosis is a systemic disease which causes thickening of the artery wall and narrows the channel that blood takes through the artery. It occurs in vessels all over the body beginning about the age of 30, but some people develop atherosclerosis faster than others. Risk factors include increased age, family history, high blood pressure, high cholesterol, diabetes and smoking.

Carotid artery disease is the cause of more than half of all strokes. Stroke, in turn, is the third highest cause of death and the leading cause of disability in the United States. Most strokes are caused by emboli. Emboli are small particles of plaque or blood clot that forms on the irregular surface of the plaque, which break loose and travel downstream to block small arteries in the brain.

How is Carotid Artery Disease Diagnosed?

In some cases, the first symptom of carotid artery disease may be a stroke or a mini stroke called Transient Ischemic Attack (TIA). Symptoms of a stroke or TIA may include:

• Numbness or weakness in the arms or legs, especially when limited to one side of the body
• Drooping of one side of the face
• Confusion
• Difficulty speaking or understanding speech
• A sudden episode of memory loss
• Loss of vision in one or both eyes
• Disorientation or disturbance in coordination
• Severe headache

Transient symptoms completely resolving in a few minutes or hours indicate a “mini” stroke (TIA). Stroke is the persistence of symptoms for 24 hours or more.

Narrowing (stenosis) of the carotid arteries can also occur without any signs or symptoms. These asymptomatic stenoses in the carotid arteries are sometimes discovered during a routine examination, when a “bruit,” a swishing sound, is heard through a stethoscope placed on the neck in the area of the artery.

When your doctor suspects that you have stenosis in your carotid arteries, she or he may order an ultrasound.

How is Carotid Artery Disease Treated?

Asymptomatic patients with mild to moderate carotid artery disease (less than 80% stenosis) are followed by serial exams or ultrasounds. Controlling risk factors for atherosclerosis helps to slow the progression of the disease. The goals of medical treatment include blood pressure control, reduction of cholesterol levels and tobacco cessation.

(LINK TO TAM PROGRAM, LINK TO TOBACCO CESSATION PROGRAMS)

People with strokes or TIAs related to carotid stenosis and asymptomatic patients with severe disease (greater than 80% stenosis) are usually treated with an operation called carotid endarterectomy. In selected patients, a minimally invasive procedure called carotid stenting may be considered.

Carotid Endarterectomy

Carotid endarterectomy is a surgical procedure that involves removing plaque from the carotid artery. The surgery takes approximately one-and-a-half to two hours and usually performed under a general anesthetic. The surgeon first makes a small incision on the side of the neck to expose the artery. The artery is clamped and opened length-ways. The plaque is peeled out and then the artery is sutured closed. Sometimes a shunt (silicon tube) is used to temporarily divert blood flow around the area of the artery being operated on. In most cases, the surgeon closes the artery by sewing a synthetic patch to the open edges of the artery. This widens the vessel to decrease the chances of recurrent stenosis. Under normal circumstances, the procedure requires only an overnight stay in the hospital.

The risks of this procedure include heart attack, abnormal heart rhythm and stroke. Nationwide, the risk of stroke or TIA around the time of surgery is 1-3%.

Carotid Stenting

A stent is a small, metal tube that, once placed within the blocked artery, acts as a scaffold to keep the artery open. The stent is loaded on a thin tube with a balloon at the end called a balloon catheter. The catheter is inserted into the femoral artery in the groin through a needle puncture and is then guided up to the stenotic (narrowed) portion of the artery. The stent is deployed when the balloon is inflated. The balloon catheter is removed and the stent remains inside the artery permanently in order to help hold the artery open.

Carotid stenting is a minimally invasive technique and is usually done under a local anesthetic with mild sedation. Because the stroke risk, efficacy and long-term outcome of this procedure have not been fully evaluated, it is currently advised for patients who are not optimal candidates for carotid endarterectomy and/or who are participating in a clinical trial (research study). It may be considered in patients who have had neck irradiation or prior neck surgery, conditions which increase the risk of an open surgical approach.