Carotid Artery Disease and Stroke: Prevention and Treatment | Q&A

I’ve performed over 1600 carotid and
arteritic procedures at Johns Hopkins overthe years, but without question the most
rewarding and gratifying part ofmy practice in terms of carotid disease,
is reassuring patients that theydon’t need an operation and they’re not at
high risk of stroke. Stroke, in my opinion, is themost devastating complication of
cardiovascular disease. It devastates lives. One year after stroke, two-thirds ofsurvivors are left with significant
functional deficits. That’s our third leading cause of death,
our second leading cause ofdementia and the number one cause of adult
disability in America today. And patients are terribly scared when they
hear the word stroke. I see lots and lots of patients, almost on
a weekly basis,who have had a duplex scan, often in a
community screening, a study. And they have a piece of paper that saysthey have carotid disease and they’re at
risk of stroke. And we see them. We evaluate them comprehensively, we get aduplex scan in our accredited vascular
laboratoryand find that they only have modestdisease at most and they’re best treated
medically. I’ve got patients like that I’ve been
following for ten or 20 years. I enjoy performing carotid surgery, but
it’s terribly gratifyingto be able to put someone’s mind at ease. Tell them they don’t need an operation,
and they’re not at risk of stroke. The term vascular surgeon is really a
misnomer becausevascular surgeons do much, much more than
conventional surgery. We diagnose the condition, we perform the
duplex scans in our vascular laboratories. And we perform both carotid andarterectomy, and carotid angioplasty and
stent procedures. I think it’s, it’s sort of important to
emphasizethat only when a patient sees a physician
or groupof physicians who have all the tools in
theirtoolbox, we have all of the modalities of
treatment available. Only then will that patient be guaranteed
that they’re gonna get the treatment thatthey’re most in need of rather thana particular treatment that a particular
specialist offers. The carotid arteries are the two major
blood vessels in the neck,one on each side that deliver blood and
oxygen to the brain. Carotid artery disease refers to the
progressive blockageof these vessels due to the build up ofplaque made up of cholesterol, calcium,
fibrous tissue andblood clots that deprives the brain of
adequate oxygen. . There are over 700,000 strokes that occur
each year in the United States. And carotid artery disease is one of themost important and completely preventable
causes of stroke. Stroke occurs when these blockages in the
carotidartery limit blood flow so that cell death
occurs. Or when bits of the plaque break off and
lodge in the tiny vessels in thebrain, again limiting oxygen supply,
leading to celldeath and the development of a clinical
stroke. The prevalence of carotid artery disease
increases with advancing age. Although it can occur in younger
individuals,most patients are over the age of 65. Other factors that contribute to the
development of carotidartery disease include high bloodpressure, hypertension, elevated
cholesterol levels. Diabeties and certainly cigarette smoking. The most appropriate treatment for a
patientwith carotid artery disease depends on two
factors. First, the severity of the blockage itself
and the patient’s symptomatic status. The severity of the blockage is best
determinedby performance of a carotid duplex
ultrasound examination. This is a noninvasive, relatively quick,
and relatively inexpensive testthat not only tells us how severe the
artery is blocked. But also allows us noninvasively to
examine the plaque, andthe character of that plaque, which has
future prognostic significance. The other issue is the patient’s
symptomatic status. Most patients with carotid disease are
completely asymptomatic when they present. And when we know about them, it’s
typically because they’ve had a or a sound in the neck that was picked up
by a stethoscope. For those patients, unless the blockage isreally severe, the optimal treatment is
medical management. This includes the use of aspirin which isa powerful anti platelet or anti clotting
drug. Use of stat medications which not onlylowers cholesterol levels but actually
stabilize theplaque itself and has been shown innumerous studies to reduce stroke risk
long term. And good blood pressure control and again
certainly stopping smoking. On the other hand, once a patient has
become symptomatic, that is either had astroke or a so called mini stroke orTIA transient ischemic attack, then
intervention is required. The standard conventional treatment for
symptomatic carotiddisease and also asymptomatic disease that
isvery, very severe, that is typically
greaterthan 80% blocked, is a carotid
endarterectomy. This operation is really the gold standard
treatment for carotid disease. It’s been around, it’s been performed for
more than 50 years. And it’s been highly studied and very well
perfected. In this operation the surgeon makes an
incision overthe artery, opens the vessel and directly
removes the plaque. And then repairs the artery. It can be performed either under general
anaesthesia or with local anaesthesiaby numbing the skin, depending upon the
surgeon’s and the patient’s preference. It takes about an hour to do the
procedure, and recovery is very quick. Most patients are discharged the day after
surgery. An alternative to carotid endarterectomy
today is carotid angioplasty and stenting. This is generally reserved for patients
considered to be at too high riskfor open surgery and it’s, it’s anapproach that is still under clinical
investigation. In this procedure, the skin in the groin
is numbed up with a local anaesthesia,a needle is introduced, a catheter isintroduced, and threaded up into the
carotid artery. Dye is injected, and a picture on our
turogramof the carotid artery is obtained, and
then aballoon is inserted and dilated up, to
open theblockage, and then a stent is usual,
usually placed. They hold the blockage open and again
aftercarotid angioplasty and stent and recovery
is very quick. Most patients go home the day after
surgery. Recovery from carotid endarterectomy is
very rapid. Really, patients resume their normal
activities just aday or two after being discharged from a
hospital. The one exception is because there’s a, an
incision in the neck and it may bea bit sore, we encourage patients not todrive themselves for about a week or ten
days. Because changing lanes might be a little
bit of a challenge in similarly aftercarotid angioplasty your stem procedure
because thegroin might be a little bit sure. Again we ask patients not to drive for
about a week after theprocedure but generally patients
immediately return tothe normal quality and status of life. Although we perform these procedures to
prevent stroke, strokeis one of the potential complications of
these interventions. In a recently completed NIH trial, the
Cresttrial, the incidence of stroke was about
2%. That is one in 50 patients who had a
carotid endarterectomy versus4%, one in 25 patients who underwent a
carotid angioplasty and stent procedure. In general, I like to see my patients a
few weeks after surgery just to make surethe incision’s healing after a carotid
endarterectomy or thegroin looks okay after a carotid
angioplasty extent procedure. And then, we have the patients return once
a year,and at that time obtained a carotid duplex
ultrasound examination. Not only to look at the artery that wetreated, but also to look at the other
carotid arteryon the other side of the neck to makecertain that it’s not developing new
disease down the line. It is very important that the carotidduplex scan be performed in an accredited
laboratory. Ultrasound machines are available in many
physician’s offices, and healthcareclinics, and walk in clinics, and these
are very critical tests. The decision as to how we treat a patient
isdependent upon the information that comes
out of these tests. And only when a patient is evaluated in a
trulyaccredited vascular laboratory that has to
meet very rigorous criteria canthey be certain that the information that
they’re being givenis truly accurate in terms of determining
their most appropriate treatment. And as chief of the division of vascular
surgery andendovascular therapy, I’m most proud of
the team that we’ve recruited. Our vascular team at Johns Hopkins, all of
use share a common vision. We believe our mission is not to take care
of disease. Our mission is to take care of people. We’re all committed to one goal, that is
to do themost appropriate thing to optimize the
vascular health of our patients. Johns Hopkins has a well deserved
reputationas an outstanding center for research and
teaching. And we’re an international center of
excellence in clinical care. Diagnosing and treating the entire gamut
disease fromthe various attack to the every day
routine processes. I think sometimes what gets lost in this
well-deserved reputationis the human touch inherent in the care
that we deliver. Johns Hopkins physicians truly care about
patients as people. And that’s something that we’re most proud
of.