Carotid arterial disease is a condition involving the narrowing of the carotid arteries (located in the front portion of your neck) due to a buildup of fatty plaque. This is the result of atherosclerosis, a condition where the arteries harden and narrow as a result of plaque buildup. The carotid arteries are responsible for supplying blood to the brain. If the artery becomes too narrow and blood flow is reduced, the brain will not receive the amount of blood it requires, increasing the risk of a stroke. The extent of the narrowing and the patient’s current medical state will determine the type of treatment required. The purpose of carotid artery disease treatment is to lessen the chance of stroke by reducing the narrowing of the carotid arteries and removing existing plaque. Treatment can involve changes to an individual’s lifestyle, medication, and/or surgery. The more severe the narrowing of the artery, the greater the risk of stroke, thus more aggressive treatment is required. The effectiveness of the various treatments will depend on the medical state of the patient, their age, and general health. In determining the ideal treatment, one must consider the risk of complications over a long-term patient to the benefit of aggressive therapy in a short-term patient.
Overview of Carotid Artery Disease
The common carotid artery splits into the internal and external carotid arteries. The internal carotid artery supplies blood to the brain, whereas the external carotid artery supplies blood to the face and neck. The carotid arteries can become narrowed or occluded by atherosclerosis: fibrous plaque development in the arteries’ walls. This narrowing of the vessel may lead to diminished cerebral blood flow and/or plaque rupture and clot formation, which can result in a stroke. A stroke occurs when the blood supply to an area of the brain is interrupted by either occlusion of an artery or rupture of an artery causing internal bleeding. Blood flow and vessel status beyond the stenosis are essential data in assessing a patient with carotid artery disease. At the present time, there are two modalities for providing this information: cerebral angiography and carotid duplex ultrasonography. Cerebral angiography is considered the gold standard for assessing carotid artery disease. However, carotid duplex ultrasonography can provide almost as much information and has become the primary screening and monitoring tool for patients with carotid artery disease. Symptoms of carotid artery disease are due to cerebral ischemia and are referred to as Transient Ischemic Attack (TIA). This is focal loss of cerebral function, persisting for less than 24 hours. Symptoms are dependent on the area of the brain which is affected. Carotid artery stenosis is a risk factor for the development of TIA, and greater than 50% of strokes are preceded by TIA. Symptoms are important when deciding on how to manage a patient with carotid artery disease. Full assessment of TIA and stroke is beyond the scope of this article.
Importance of Treatment
The treatment for carotid artery disease and the prevention of stroke may involve a combination of lifestyle changes, medicines, or surgical procedures. The more severe the narrowing of the artery and the greater the risk of stroke, the more likely it is that you will need an appropriate surgical procedure.
It is essential to understand the extent of narrowing of the carotid arteries. This will help in determining the type of treatment that is necessary for the patient. This can be done using a test called a carotid duplex ultrasound, which is a safe and painless test that can provide information about the structure and function of the blood vessels. A more detailed picture of the carotid arteries can be obtained using an MRA scan or a CT scan. These are important to help in the treatment and prevention of stroke.
The narrowing of the carotid arteries can result in a stroke. A stroke occurs if the blood supply to the brain is blocked. Depending on how severe the blockage is, a stroke can result in a transient ischemic attack (TIA), which is a temporary disturbance in brain function, to a minor stroke or a major stroke. The more severe the narrowing of the artery, the greater the risk of stroke. It is important to have good management of any of the risk factors for atherosclerosis to reduce the chance of stroke.
Carotid artery disease is a serious health problem that often occurs without any warning signs. This disease results from a process called atherosclerosis, or a narrowing of the artery due to a build-up of fatty substances and cholesterol. The build-up on the walls of the arteries is called plaque. These plaques can build up in the carotid arteries and restrict blood flow to the brain. Plaque can be the result of many factors, including smoking, high cholesterol, and high blood pressure.
Non-Surgical Treatment Options
Lowering cholesterol levels is another important way to try to prevent the progression of carotid artery disease. Statin medications are very effective at doing this and are now recommended as the preferred medication for lowering cholesterol. High cholesterol levels are also often a result of an unhealthy diet so trying to improve your diet should be considered at the same time.
Controlling high blood pressure is known to reduce progression of carotid artery disease. There are many different medications that can be used to control blood pressure and your doctor will be able to discuss which one is most suitable for you.
If you have particularly narrow carotid arteries or have had a TIA or minor stroke already, then it is possible that your doctor may suggest a surgical method of preventing a stroke, carotid endarterectomy, instead of or as well as these medications. This is discussed in more detail below under the management of carotid artery disease.
Anti-platelet medications such as aspirin or clopidogrel are important in the medical treatment of carotid artery disease. They can help to prevent a stroke occurring either by stabilising the atheroma so that small parts do not break off and cause a TIA or stroke, or by preventing blood clots forming on the surface of the atheroma. Sometimes the side effects of these medications can cause a problem so regular check-ups with a doctor are important.
Medications for Carotid Artery Disease
There are many types of medications that can be used to treat carotid artery disease. If you have had a TIA or stroke, or if you have severe carotid artery disease, you should especially think about taking antiplatelet or anticoagulant medications. These medicines affect your blood’s clotting function. If you have disease but have never had symptoms and you are considering surgery, taking antiplatelet agents may reduce your risk of stroke before and shortly after surgery. In some people with carotid artery disease and coronary artery disease, antiplatelet medications can also reduce the risk of a heart attack. The two most recommended antiplatelet medications are aspirin and clopidogrel. Aspirin is often the first choice because it works well and is low cost. Clopidogrel is an alternative for people who do not take aspirin because of allergy or other medical reasons. There are also some individuals who despite being on antiplatelet therapy will have recurrent symptoms. If it is determined that their carotid disease is the likely source, there may be consideration of adding stronger anticoagulant medications. You should consult your physician to decide what is the best course for you. Keep in mind that these are blood-thinning medications, and there is an increased risk of bleeding with their use. It is important that you understand both the risks and benefits of any of these medications before starting them.
Lifestyle Changes for Managing the Disease
Quit smoking. Smoking doubles the risk of stroke. It damages blood vessel walls, speeds up the clogging of arteries, raises blood pressure, and increases the buildup of cholesterol. In addition to having a detrimental effect on your carotid artery disease, it negates the effect of medications that are used to prevent strokes. Seek help from your doctor if you are having problems stopping. You are more likely to quit smoking for good if you have a good support system.
Exercise. Regular physical activity can help you maintain a healthy weight and lower your blood pressure and cholesterol levels. It’s important to do some type of exercise regularly. Ideally, you should aim for at least 30 minutes of moderate-intensity physical activity on five or more days a week.
Healthy eating. A healthy diet is an important part of your overall cardiovascular health. A diet rich in fruits, vegetables, and whole grains can help protect your heart. Limiting the amount of saturated fat and cholesterol that you eat is also important. Eating healthy is an important part of your overall cardiovascular health and will help lower your blood pressure and cholesterol levels.
Making lifestyle changes is an important step in controlling carotid artery disease. You can’t control some factors, such as age, family history, and gender. But other risk factors can be controlled, and it’s important to take action. The following changes may help you reduce your chances of stroke.
Monitoring and Regular Check-ups
Your doctor may decide to refer you to a specialist to decide what the best form of treatment is for you. This decision will be based on your age, general health, and the severity of the narrowing in your carotid arteries, to name a few things. The specialist is likely to be a vascular surgeon or a neurologist. These are the two types of doctors that are primarily involved in preventing strokes related to carotid artery disease and have the most experience in the area.
Your doctor will want to find the most likely source of the first event. If it is carotid artery disease, the goal will be to prevent more events by removing the buildup of fatty deposits in the carotid arteries. This can be done by making changes to your lifestyle, through medication, or a combination of both. What treatment is best for you will depend on your particular circumstances.
Having the first “mini stroke” (transient ischemic attack) or stroke is often a wake-up call. It’s a sign that damage is already done, and more is likely without intervention. It is a dangerous time, and steps to prevent another stroke are a top priority.
Surgical Treatment Options
Carotid angioplasty and stenting has been offered as an alternative to endarterectomy. This is a less invasive procedure which involves a sheath being inserted into the femoral artery in the groin. High-grade stenosis may have previously resulted in a stroke.
Carotid endarterectomy is a proven method of stroke prevention in patients with severe carotid artery stenosis. This procedure involves surgical exposure of the carotid artery in the neck under general anesthesia. The artery is opened and any irregularities of the inner surface are smoothed out. A longitudinal incision is made into the artery and the atheromatous plaque is dissected away. The plaque is often removed by directing blood flow through a shunt. The incision is then closed with a patch to widen the artery and reduce the risk of recurrent stenosis. Many patients will remain in the hospital for one to two days after the procedure. This is an effective treatment with an annual risk of stroke of less than 3%.
Carotid artery disease is a very serious condition with significant risks. There are two main surgical treatment options for carotid artery disease: endarterectomy and angioplasty with stenting. The first involves removing the plaque from inside the carotid artery, which is a major artery that supplies blood to the brain. The second involves placing a small metallic mesh tube called a stent inside the artery to help keep it open and decrease the risk of stroke. The choice of treatment depends on the patient’s medical condition, the location of the blockage, and the surgeon’s experience.
Carotid Endarterectomy Procedure
Since the early 1990s, surgeons have been able to perform a carotid angioplasty and stenting, a minimally invasive treatment for carotid artery disease in high-risk patients who have serious heart disease, lung disease, or have previously had neck radiation, or in patients who also have a significant narrowing of the other carotid artery. This treatment involves threading a catheter through the femoral artery to the blocked artery in the neck. This results in a much less obvious scar compared to the regular surgical method. A protection device is used to prevent plaque from the artery entering the brain. Later, an expandable stent is placed in the artery at the treatment site to hold the plaque out of the way. The protection device is then removed and the catheter and sheath are taken out of the patient. The results of this procedure may vary, and to date, the long-term effectiveness of carotid angioplasty and stenting is still undetermined.
Carotid endarterectomy is a surgical procedure to remove plaque from the carotid arteries. Located on each side of the neck, these arteries supply blood to the brain. The procedure involves a skin incision on the neck over the diseased artery, followed by the insertion of a tube to reroute blood around the section of the artery containing the atherosclerotic plaque. The artery is then opened and the plaque is removed. Upon finishing this process, the tube is removed and the artery and skin incision are closed. The direct costs of carotid surgery are approximately $15,000, with hospital fees comprising the largest part.
Carotid Artery Stenting Procedure
Carotid artery stenting is a procedure used to restore a more normal blood flow through the artery in patients with carotid artery disease. It is an alternative to carotid endarterectomy, which is another method used to treat carotid artery disease. Carotid endarterectomy is a surgical procedure in which plaque is removed from the artery through a skin incision made in the neck. There are many factors that can increase a patient’s risk of complications from carotid endarterectomy, so carotid artery stenting may be considered for patients who are at high risk for complications from endarterectomy. The first carotid artery stenting was performed in 1993, but it is still a relatively new procedure and no long-term data is available at this time. Carotid artery stenting is done by a specialist called an interventional neuroradiologist. This procedure is similar to heart angioplasty. It involves inserting a catheter into an artery in the groin, running it all the way up to the narrowed carotid artery in the neck, and then inflating a small balloon to open the artery. A metal stent is placed in the artery to keep the blood flowing and the plaque away from the brain. The stent is less likely to become re-narrowed by plaque and is expected to have better long-term results than the balloon alone, but this is still being studied. Carotid artery stenting has less risk for certain complications than endarterectomy, especially in patients with severe heart or lung disease. However, it has a slightly higher risk for causing a stroke or death during the procedure, and it may still carry a risk for nerve damage that results in a stroke after the procedure. So the choice between stenting and endarterectomy depends on each patient’s individual medical conditions, as well as their own values and concerns about the potential benefits and risks of each procedure.
The carotid arteries are the blood vessels on each side of your neck that bring your brain and head with oxygen and nutrients in your blood. One of these arteries may become narrow or blocked, usually by a harmful wad of plaque. Plaque is made up of extra cholesterol, calcium, and other substances that are found in the blood. A narrowing in a carotid artery can increase your risk of stroke. Stroke is caused when the brain is damaged by lack of blood and oxygen. A piece of plaque from the carotid artery can break loose, travel to the brain, and completely block an artery that supplies blood to the brain. Carotid artery disease is a serious health concern, but the US Veterans Affairs Health Care System does offer treatment at its various facilities.
Benefits and Risks of Surgical Treatments
The benefits of both stenting and endarterectomy are that they can help prevent stroke in patients with severe carotid artery disease. The risks of any stroke for patients with severe carotid artery stenosis who undergo the procedures are lower than the risk of having a stroke if they are treated with just medical therapy. However, because the trials testing the relative safety and efficacy of these procedures compared them to medical therapy, it is unknown whether an individual patient’s risk of stroke with medical therapy is the same as the risk in the trials. Also, the trials generally excluded patients with severe carotid artery disease who were asymptomatic as well as patients with certain comorbid conditions, so the efficacy and safety of these procedures in these populations are not well established. Although the risks and benefits of these procedures vary by age and sex, there are no reliable methods to determine an individual patient’s risk when the patient has comorbid conditions.
Post-Treatment Care and Rehabilitation
Recovery Process Your recovery after carotid intervention will vary depending on your health prior to the procedure and the type of treatment. Complete recovery may take 2-4 weeks if you have not had a disabling stroke or heart attack. If you have suffered a stroke or heart attack, your recovery may take longer. In general, you should be able to resume normal activities within a few weeks. During recovery, you may want to have help available for those activities that require more physical exertion. This should allow you to gradually return to your normal level of activity, giving your body the necessary time to heal.
Because carotid artery disease is a chronic health condition, you may experience its symptoms or complications again in the future. Managed lifestyle changes and adherence to medication and follow-up care after an intervention are very important to reduce the risk of further problems related to carotid artery disease. This is especially important after carotid endarterectomy, which you may have undergone to reduce your risk of stroke.
Recovery Process
A recovery plan for patients following CEA or CAS is aimed at full return to normal activity, prevention of recurrent stroke, and prevention of other cardiovascular diseases. Most patients will be managed by a team of skilled nurses, physical and occupational therapists, dietitians, and physicians. Disabling medical conditions associated with stroke, such as weakness, paralysis, or speech and swallowing problems, often require special care and rehabilitation. Physical and occupational therapy are important parts of the recovery process. A structured exercise program, such as walking, is important for rehabilitation, but it should be discussed with a physician or a member of the medical team. Ataxia and gait disturbances are common after stroke. These often resolve over time with general physical conditioning. In CASPER patients, we believe that asymptomatic carotid stenosis patients, in particular, have the most to lose from stroke, and we will be investigating whether a formal supervised exercise program can prevent cognitive decline. Patients should be cautious of increased ischemic symptoms with exercise. When these occur, the intensity of exercise should be decreased. A very small number of patients will have had a stroke while already under medical treatment for symptomatic carotid disease. Secondary prevention at this point is even more vital. Subsequent strokes in these patients are often devastating.
Follow-up Care and Medication Management
Diet, exercise and quitting smoking are all very important factors to managing your overall health. Your doctor may have a dietician or healthcare provider who can help you understand what kinds of changes or goals are needed. A good balanced diet can help to make sure you are getting the kinds and amounts of food needed for nutrition and energy. Adding exercise into your everyday activities can also add energy and health. Consulting a healthcare provider about exercise is also important. You and your provider can plan goals and activities that will help improve your overall health. Regular health check-ups are also important to measure the success of treatment. This is also a time for the healthcare provider to detect and treat any new complications of the disease.
This portion of treatment is important and may involve your regular doctor or a specialist. Treatment may include lifestyle changes, taking medicine, or possibly a combination of both lifestyle changes and medicine. This will depend on your overall health, the severity of the disease, and what your doctor recommends. Medical management may be a good choice if you have serious health problems. No matter what treatment is recommended, making lifestyle changes is important for your overall health.
Lifestyle Modifications for Long-Term Health
Cigarette smoking is a well-established risk factor for the progression of carotid artery stenosis and stroke. Smoking cessation is an important and effective strategy for reducing the risk of stroke, with benefits becoming clear within 2-4 years of cessation.
Diabetes is an independent risk factor for stroke, and its presence doubles the risk of stroke death. Tight control of blood glucose levels with diet, weight loss, exercise, and medications can prevent the development of diabetes-related complications and reduce the risk of stroke.
Hypertension is one of the most powerful and prevalent risk factors for both stroke and progression of carotid disease. Approximately half of all strokes are attributable to high blood pressure. Weight reduction, adopting the DASH diet (high in fruits, vegetables, and low-fat dairy products with reduced saturated and total fat), dietary sodium reduction, regular aerobic physical activity, and moderation of alcohol consumption are all strategies for prevention and control of hypertension.
