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

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

October 29, 2019 25 By William Morgan


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I’ve performed over 1600 carotid and
arteritic procedures at Johns Hopkins over
the years, but without question the most
rewarding and gratifying part of
my practice in terms of carotid disease,
is reassuring patients that they
don’t need an operation and they’re not at
high risk of stroke.
Stroke, in my opinion, is the
most devastating complication of
cardiovascular disease.
It devastates lives.
One year after stroke, two-thirds of
survivors are left with significant
functional deficits.
That’s our third leading cause of death,
our second leading cause of
dementia 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 says
they have carotid disease and they’re at
risk of stroke.
And we see them.
We evaluate them comprehensively, we get a
duplex scan in our accredited vascular
laboratory
and find that they only have modest
disease 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 gratifying
to 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.
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The term vascular surgeon is really a
misnomer because
vascular 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 and
arterectomy, and carotid angioplasty and
stent procedures.
I think it’s, it’s sort of important to
emphasize
that only when a patient sees a physician
or group
of physicians who have all the tools in
their
toolbox, we have all of the modalities of
treatment available.
Only then will that patient be guaranteed
that they’re gonna get the treatment that
they’re most in need of rather than
a particular treatment that a particular
specialist offers.
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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 blockage
of these vessels due to the build up of
plaque made up of cholesterol, calcium,
fibrous tissue and
blood clots that deprives the brain of
adequate oxygen.
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There are over 700,000 strokes that occur
each year in the United States.
And carotid artery disease is one of the
most important and completely preventable
causes of stroke.
Stroke occurs when these blockages in the
carotid
artery limit blood flow so that cell death
occurs.
Or when bits of the plaque break off and
lodge in the tiny vessels in the
brain, again limiting oxygen supply,
leading to cell
death and the development of a clinical
stroke.
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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 carotid
artery disease include high blood
pressure, hypertension, elevated
cholesterol levels.
Diabeties and certainly cigarette smoking.
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The most appropriate treatment for a
patient
with 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
determined
by performance of a carotid duplex
ultrasound examination.
This is a noninvasive, relatively quick,
and relatively inexpensive test
that not only tells us how severe the
artery is blocked.
But also allows us noninvasively to
examine the plaque, and
the 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 [UNKNOWN]
or a sound in the neck that was picked up
by a stethoscope.
For those patients, unless the blockage is
really severe, the optimal treatment is
medical management.
This includes the use of aspirin which is
a powerful anti platelet or anti clotting
drug.
Use of stat medications which not only
lowers cholesterol levels but actually
stabilize the
plaque itself and has been shown in
numerous 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 a
stroke or a so called mini stroke or
TIA transient ischemic attack, then
intervention is required.
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The standard conventional treatment for
symptomatic carotid
disease and also asymptomatic disease that
is
very, very severe, that is typically
greater
than 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 over
the 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 anaesthesia
by 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.
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An alternative to carotid endarterectomy
today is carotid angioplasty and stenting.
This is generally reserved for patients
considered to be at too high risk
for open surgery and it’s, it’s an
approach 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 is
introduced, and threaded up into the
carotid artery.
Dye is injected, and a picture on our
turogram
of the carotid artery is obtained, and
then a
balloon is inserted and dilated up, to
open the
blockage, and then a stent is usual,
usually placed.
They hold the blockage open and again
after
carotid angioplasty and stent and recovery
is very quick.
Most patients go home the day after
surgery.
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Recovery from carotid endarterectomy is
very rapid.
Really, patients resume their normal
activities just a
day or two after being discharged from a
hospital.
The one exception is because there’s a, an
incision in the neck and it may be
a bit sore, we encourage patients not to
drive themselves for about a week or ten
days.
Because changing lanes might be a little
bit of a challenge in similarly after
carotid angioplasty your stem procedure
because the
groin might be a little bit sure.
Again we ask patients not to drive for
about a week after the
procedure but generally patients
immediately return to
the normal quality and status of life.
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Although we perform these procedures to
prevent stroke, stroke
is one of the potential complications of
these interventions.
In a recently completed NIH trial, the
Crest
trial, the incidence of stroke was about
2%.
That is one in 50 patients who had a
carotid endarterectomy versus
4%, one in 25 patients who underwent a
carotid angioplasty and stent procedure.
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In general, I like to see my patients a
few weeks after surgery just to make sure
the incision’s healing after a carotid
endarterectomy or the
groin 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 we
treated, but also to look at the other
carotid artery
on the other side of the neck to make
certain that it’s not developing new
disease down the line.
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It is very important that the carotid
duplex scan be performed in an accredited
laboratory.
Ultrasound machines are available in many
physician’s offices, and healthcare
clinics, and walk in clinics, and these
are very critical tests.
The decision as to how we treat a patient
is
dependent upon the information that comes
out of these tests.
And only when a patient is evaluated in a
truly
accredited vascular laboratory that has to
meet very rigorous criteria can
they be certain that the information that
they’re being given
is truly accurate in terms of determining
their most appropriate treatment.
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And as chief of the division of vascular
surgery and
endovascular 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 the
most appropriate thing to optimize the
vascular health of our patients.
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Johns Hopkins has a well deserved
reputation
as 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 from
the various attack to the every day
routine processes.
I think sometimes what gets lost in this
well-deserved reputation
is 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.
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