Carotid Artery Disease and Stroke: Prevention and Treatment | Q&A
I’ve performed over 1600 carotid andarteritic procedures at Johns Hopkins overthe years, but without question the mostrewarding and gratifying part ofmy practice in terms of carotid disease,is reassuring patients that theydon’t need an operation and they’re not athigh risk of stroke. Stroke, in my opinion, is themost devastating complication ofcardiovascular disease. It devastates lives. One year after stroke, two-thirds ofsurvivors are left with significantfunctional deficits. That’s our third leading cause of death,our second leading cause ofdementia and the number one cause of adultdisability in America today. And patients are terribly scared when theyhear the word stroke. I see lots and lots of patients, almost ona weekly basis,who have had a duplex scan, often in acommunity screening, a study. And they have a piece of paper that saysthey have carotid disease and they’re atrisk of stroke. And we see them. We evaluate them comprehensively, we get aduplex scan in our accredited vascularlaboratoryand find that they only have modestdisease at most and they’re best treatedmedically. I’ve got patients like that I’ve beenfollowing for ten or 20 years. I enjoy performing carotid surgery, butit’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 amisnomer becausevascular surgeons do much, much more thanconventional surgery. We diagnose the condition, we perform theduplex scans in our vascular laboratories. And we perform both carotid andarterectomy, and carotid angioplasty andstent procedures. I think it’s, it’s sort of important toemphasizethat only when a patient sees a physicianor groupof physicians who have all the tools intheirtoolbox, we have all of the modalities oftreatment available. Only then will that patient be guaranteedthat they’re gonna get the treatment thatthey’re most in need of rather thana particular treatment that a particularspecialist offers. The carotid arteries are the two majorblood vessels in the neck,one on each side that deliver blood andoxygen to the brain. Carotid artery disease refers to theprogressive blockageof these vessels due to the build up ofplaque made up of cholesterol, calcium,fibrous tissue andblood clots that deprives the brain ofadequate oxygen. . There are over 700,000 strokes that occureach year in the United States. And carotid artery disease is one of themost important and completely preventablecauses of stroke. Stroke occurs when these blockages in thecarotidartery limit blood flow so that cell deathoccurs. Or when bits of the plaque break off andlodge in the tiny vessels in thebrain, again limiting oxygen supply,leading to celldeath and the development of a clinicalstroke. The prevalence of carotid artery diseaseincreases with advancing age. Although it can occur in youngerindividuals,most patients are over the age of 65. Other factors that contribute to thedevelopment of carotidartery disease include high bloodpressure, hypertension, elevatedcholesterol levels. Diabeties and certainly cigarette smoking. The most appropriate treatment for apatientwith carotid artery disease depends on twofactors. First, the severity of the blockage itselfand the patient’s symptomatic status. The severity of the blockage is bestdeterminedby performance of a carotid duplexultrasound examination. This is a noninvasive, relatively quick,and relatively inexpensive testthat not only tells us how severe theartery is blocked. But also allows us noninvasively toexamine the plaque, andthe character of that plaque, which hasfuture prognostic significance. The other issue is the patient’ssymptomatic status. Most patients with carotid disease arecompletely asymptomatic when they present. And when we know about them, it’stypically because they’ve had a or a sound in the neck that was picked upby a stethoscope. For those patients, unless the blockage isreally severe, the optimal treatment ismedical management. This includes the use of aspirin which isa powerful anti platelet or anti clottingdrug. Use of stat medications which not onlylowers cholesterol levels but actuallystabilize theplaque itself and has been shown innumerous studies to reduce stroke risklong term. And good blood pressure control and againcertainly stopping smoking. On the other hand, once a patient hasbecome symptomatic, that is either had astroke or a so called mini stroke orTIA transient ischemic attack, thenintervention is required. The standard conventional treatment forsymptomatic carotiddisease and also asymptomatic disease thatisvery, very severe, that is typicallygreaterthan 80% blocked, is a carotidendarterectomy. This operation is really the gold standardtreatment for carotid disease. It’s been around, it’s been performed formore than 50 years. And it’s been highly studied and very wellperfected. In this operation the surgeon makes anincision overthe artery, opens the vessel and directlyremoves the plaque. And then repairs the artery. It can be performed either under generalanaesthesia or with local anaesthesiaby numbing the skin, depending upon thesurgeon’s and the patient’s preference. It takes about an hour to do theprocedure, and recovery is very quick. Most patients are discharged the day aftersurgery. An alternative to carotid endarterectomytoday is carotid angioplasty and stenting. This is generally reserved for patientsconsidered to be at too high riskfor open surgery and it’s, it’s anapproach that is still under clinicalinvestigation. In this procedure, the skin in the groinis numbed up with a local anaesthesia,a needle is introduced, a catheter isintroduced, and threaded up into thecarotid artery. Dye is injected, and a picture on ourturogramof the carotid artery is obtained, andthen aballoon is inserted and dilated up, toopen theblockage, and then a stent is usual,usually placed. They hold the blockage open and againaftercarotid angioplasty and stent and recoveryis very quick. Most patients go home the day aftersurgery. Recovery from carotid endarterectomy isvery rapid. Really, patients resume their normalactivities just aday or two after being discharged from ahospital. The one exception is because there’s a, anincision in the neck and it may bea bit sore, we encourage patients not todrive themselves for about a week or tendays. Because changing lanes might be a littlebit of a challenge in similarly aftercarotid angioplasty your stem procedurebecause thegroin might be a little bit sure. Again we ask patients not to drive forabout a week after theprocedure but generally patientsimmediately return tothe normal quality and status of life. Although we perform these procedures toprevent stroke, strokeis one of the potential complications ofthese interventions. In a recently completed NIH trial, theCresttrial, the incidence of stroke was about2%. That is one in 50 patients who had acarotid endarterectomy versus4%, one in 25 patients who underwent acarotid angioplasty and stent procedure. In general, I like to see my patients afew weeks after surgery just to make surethe incision’s healing after a carotidendarterectomy or thegroin looks okay after a carotidangioplasty extent procedure. And then, we have the patients return oncea year,and at that time obtained a carotid duplexultrasound examination. Not only to look at the artery that wetreated, but also to look at the othercarotid arteryon the other side of the neck to makecertain that it’s not developing newdisease down the line. It is very important that the carotidduplex scan be performed in an accreditedlaboratory. Ultrasound machines are available in manyphysician’s offices, and healthcareclinics, and walk in clinics, and theseare very critical tests. The decision as to how we treat a patientisdependent upon the information that comesout of these tests. And only when a patient is evaluated in atrulyaccredited vascular laboratory that has tomeet very rigorous criteria canthey be certain that the information thatthey’re being givenis truly accurate in terms of determiningtheir most appropriate treatment. And as chief of the division of vascularsurgery andendovascular therapy, I’m most proud ofthe team that we’ve recruited. Our vascular team at Johns Hopkins, all ofuse share a common vision. We believe our mission is not to take careof disease. Our mission is to take care of people. We’re all committed to one goal, that isto do themost appropriate thing to optimize thevascular health of our patients. Johns Hopkins has a well deservedreputationas an outstanding center for research andteaching. And we’re an international center ofexcellence in clinical care. Diagnosing and treating the entire gamutdisease fromthe various attack to the every dayroutine processes. I think sometimes what gets lost in thiswell-deserved reputationis the human touch inherent in the carethat we deliver. Johns Hopkins physicians truly care aboutpatients as people. And that’s something that we’re most proudof.