Features November 2015 Issue

Know Your Options When It’s Time to Clean Out Clogged Carotid Arteries

If these neck arteries are blocked, surgery and stenting both may improve blood flow

ultrasound test

Image: Thinkstock

A Doppler ultrasound test uses high-frequency sound waves to create pictures of the insides of your carotid arteries and find any blockage.

Your carotid arteries are the major pipelines in your neck supplying blood to the brain.

They’re also a common location where fatty atherosclerotic plaques form, increasing the risk of stroke.

If atherosclerosis results in significant stenosis (narrowing) of the carotids, you may require a surgery known as carotid endarterectomy or minimally invasive angioplasty with stenting to unclog them, especially if you’ve experienced symptoms.

“Both of them are very effective treatments that are roughly equivalent in terms of recovery time and complications,” says Peter Rasmussen, MD, Director of Cleveland Clinic’s Cerebrovascular Center.

The choice of treatment depends largely on your overall health and other individual patient characteristics. And, regardless of the procedure, you’ll need to follow up with your physician and work to modify your cardiovascular risk factors.

When to intervene

Carotid artery disease often does not cause symptoms until it severely narrows or blocks an artery. Sometimes, but not often, a doctor may hear a bruit (a whooshing sound suggesting blood rushing through a narrowed artery) while listening to your neck arteries through a stethoscope. Unfortunately, the only warning signs you get may be the symptoms of a transient ischemic attack or stroke.

If your doctor suspects carotid artery disease based on your symptoms, medical history or cardiovascular risk factors (high blood pressure, cholesterol abnormalities, diabetes, obesity, smoking), he or she may order a carotid ultrasound, as well as other testing to confirm any ultrasound findings, gauge your stroke risk, and guide treatment decisions.

For mild carotid stenosis with no symptoms, treatment entails lifestyle changes (a heart-healthy diet, appropriate exercise and, if applicable, smoking cessation and weight loss), an antiplatelet drug such as aspirin or clopidogrel (Plavix®) to reduce stroke risk, and any therapy needed to manage risk factors.

Guidelines vary about when to intervene with endarterectomy or carotid stenting. However, “General scientific consensus is that if you have neurologic symptoms that are deemed to be caused by blockage in the carotid artery, the amount of stenosis that would lead a physician to recommend the artery be cleaned out is 50 percent,” Dr. Rasmussen explains. “If there are no neurologic symptoms and the artery is narrowed at least 80 percent, an endarterectomy would be recommended, as long as the patient has at least a two-year life expectancy.”

Clearing the artery

In an endarterectomy, the surgeon makes an incision in the neck and removes plaque from the artery. In carotid angioplasty and stenting, a physician inserts a catheter through a blood vessel in the groin and guides it to the blockage. The balloon is inflated to open the carotid artery, and a stent is placed to keep the artery open.

In a study published Feb. 7, 2015, in The Lancet, researchers found no significant differences in the rate of disabling or fatal strokes between the two treatments, but stenting was associated with greater risks of non-disabling strokes.

In general, symptomatic patients at high surgical risk because of a recent heart attack or co-morbid conditions such as heart failure, kidney failure, or severe lung disease are candidates for carotid stenting, Dr. Rasmussen says.

Several anatomic factors also may determine which treatment you receive. For example, if the carotid narrowing or blockage is located too high in the neck, it may be more difficult to access it surgically behind the jaw. Also, a previous endarterectomy or radiation treatment in the head, neck or mouth can make surgery more difficult. In these cases, carotid stenting may be preferable, Dr. Rasmussen explains. Conversely, certain anatomical features of the arteries may make it difficult to feed the catheter and stent to the blockage, necessitating endarterectomy.

“My general advice is if you can tolerate general anesthesia and can have an endarterectomy based on anatomic factors, you should have the endarterectomy done. My personal feeling is it’s slightly better,” Dr. Rasmussen says. “But stenting is roughly equivalent to surgery and is a very good option, as well. Certainly, it’s the right thing to do if patients have co-morbidities that make surgery high risk or there are anatomic factors that make endarterectomy difficult.”

Keep in mind that the skill of the practitioner also determines the success of either treatment, Dr. Rasmussen adds: “Patients should have them done by physicians who are experienced with the procedure and do at least a half-dozen to a dozen a year.”

Follow-up care

You’ll probably go home the day after either procedure and return to full activities in about a week, Dr. Rasmussen says. Undergo follow-up ultrasound exams, at an interval set by your physician—Dr. Rasmussen sees patients between six and 12 weeks after treatment and then yearly.

“Medically, they probably don’t really require yearly follow-up after three years, but psychologically they do,” he says. “The anxiety level is pretty high about having a stroke with a recurrent blockage, so they feel good about having their arteries checked to try to minimize their stroke risk.”

After treatment, manage your risk factors with healthful lifestyle habits and the medication regimen your doctor recommends. “I stress the importance of risk-factor modification and lifestyle changes,” he says. “Smoking cessation, control of lipids, weight and diabetes, careful blood pressure control and follow-up—those are the mainstays of treatment.”

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