Carotid Artery Disease

The carotid arteries are the main arterial pathways that supply the brain. Atherosclerosis narrows these arteries, reducing the blood flow that supplies your brain, which may result in serious consequences. Sometimes, the atherosclerosis plagues can break off and block brain blood vessels, causing strokes. The incidence of cerebral atherosclerosis is high, along with coronary artery disease and lower extremity arterial disease.

Signs of the disease

The disease is asymptomatic for a long time. If patients know they have vascular problems, it is necessary that they undergo a routine Doppler ultrasound. In many countries in the world, the Doppler ultrasound is performed at least once every two years in order to keep under control the arterial/venous diseases and be able to monitor them in case of greater risks. Signs such as sudden visual disturbances, difficulty speaking, numbness, dizziness, may indicate that you could experience a transient ischemic attack. If this happens, you should go to a specialized physician to get an examination and undergo a carotid Doppler ultrasound examination, to determine whether you have carotid stenosis or occlusion.

In some cases, a transient ischemic attack (TIA) might go away without leaving any consequences, while in others it might require a long recovery. Statistically, 33% of patients who have had a TIA may experience a stroke that could have severe consequences (total or partial functional impairment, speech or memory impairments, etc.).

Necessary investigations

  • Examination by a vascular surgeon – it might reveal previous episodes of transient ischemic attacks (TIA), pathologic murmurs;
  • Carotid Doppler ultrasound: accurate measure of the degree of carotid stenosis;
  • CT angiography to examine blood vessels in the neck, including the circle of Willis – for symptomatic carotid stenosis;
  • In some cases, the surgeon will also require a Magnetic Resonance Angiography (MRA).

Treatment

Low-grade (less than 70%) and asymptomatic carotid stenosis is usually treated with medication alone, mainly addressing the risk factor mentioned above.

High-grade (more than 70%) and symptomatic stenosis should undergo surgery. Patients with critical carotid stenosis should undergo endarterectomy, stenting, angioplasty (after a certain time from the stroke). The surgeon will decide this after a thorough examination. Carotid endarterectomy will not be performed in the acute phase of the disease.

Interventional approaches for high-grade stenosis

Carotid Angioplasty and stenting (minimally invasive)

Carotid angioplasty and stenting involve widening and inserting a tube (stent) at the site of the stenosis to keep it open. This is rarely recommended, and should be used for lesions that are difficult to approach by surgery (proximal or distal), for restenosis after endarterectomy, and for difficult surgical procedures (cervical surgery, radiation). The classical surgical procedure remains the gold standard treating carotid stenosis.

Classical surgery procedure – carotid endarterectomy

The surgical procedure consists in removing the plaque that caused stenosis. During the procedure, a small incision will be made on the side of the neck over the affected area, the artery will be opened and the plaque removed. Following this procedure, the aortic wall will become thinner and smooth, and the artery will regain a normal functioning.

Risks and possible complications:

  • Bleeding or postoperative hematoma;
  • Risk of stroke during or immediately after the surgery (within 24 hours); this risk is real (3%) but much lower than the risk of having a stroke without the surgery procedure;
  • Damage nerves that are within the surgery section – sensory nerves of the external ear (which results in tickling and decreased sensitivity), or rarely, the nerve of the tongue (the hypoglossal nerve) deviating it to opposite side;
  • Risk of restenosis (<2%), the risk is even lower if a patch enlargement is used.