Carotid Artery Disease

The most common problem that I am asked to see is a blockage in the carotid artery. The vast majority of these blockages are caused by atherosclerosis (hardening of the arteries). It is important to differentiate between patients with symptoms and those that are asymptomatic. Most of the patients referred to me have no symptoms. Their blockage was discovered when someone listened to their neck with a stethoscope and heard a swishing noise called a bruit. Perhaps they had an ultrasound done as a screening test because they have a blockage elsewhere or a family history of arteriosclerosis. Symptomatic patients may not realize that they have a blockage until they have a stroke or a warning sign of a stroke (a TIA or transient ischemic attack). Some common symptoms include numbness or weakness of the opposite arm/leg, facial weakness, loss of vision in one eye, difficulty speaking. Other symptoms are non-specific such as dizziness, lightheadedness, blurred vision, passing out (syncope), headache, drop attacks, balance difficulty, etc.

For any given patient, I like to answer these questions:

Do they have carotid artery disease and, if so, how severe is it? Are they symptomatic? If they are symptomatic, are they having hemispheric symptoms or non-hemispheric symptoms? If they have had a stroke, how long ago did it occur and do they have any residual neurological deficit?

Should their carotid disease be treated? If so, what is the best treatment option for this patient (medical management, carotid endarterectomy or CEA, carotid stenting or TCAR)?

Carotid endarterectomy (CEA) has long been the gold standard for treatment of significant carotid artery blockages. Performed through an incision on the side of the neck about three inches long, this operation involves opening the artery and scraping out the plaque. In general, CEA is a fairly easy operation for patients to go through and recover from. Complications are infrequent but can be devastating. My patients are typically in the hospital 1-2 nights. It takes about 1-2 weeks to recover from carotid endarterectomy. Stroke is the most feared complication and the stroke rate is about 2% in the hands of an experienced surgeon. Of all the vascular procedures I perform, I believe CEA has the least margin for error. CEA is often a straightforward operation, but there are a number of "curveballs" that a surgeon may encounter. Some of these are variations in anatomy, some relate to the extent of the plaque, and some relate to collateral circulation to the brain. The operation can be technically challenging and surgeons who do a lot of carotid surgery are likely to be more adept at dealing with some of the nuances or pitfalls they may encounter. This is an operation where you usually only get one chance to get it right.

Transcarotid artery revascularization (TCAR) is a fairly new procedure whereby a patient's blockage is treated with a stent rather than by endarterectomy. TCAR is less invasive than CEA and has a comparable risk of peri-procedural stroke. Currently, TCAR may be considered in patients that are poor candidates for CEA for any of a number of reasons.