Carotid Endarterectomy: Stroke Prevention for Selected Patients

L. Richard Roedersheimer MD, F. A.C. S.

INTRODUCTION: Stroke remains the third leading cause of death in the United States and it is the leading cause of severe disability. Every 53 seconds someone has a stroke, every 3.3 minutes someone dies from a stroke. Of the 4.4 million stroke survivors, 29% are younger than 65. As vascular surgeons we have the capability of helping to prevent stroke by removing atherosclerosis from the carotid artery, which is one of the major arteries carrying oxygenated blood to the brain.

HOW DOES STROKE HAPPEN? Bleeding into the brain (hemorrhage) can cause strokes. When a blood vessel bursts secondary to high blood pressure or from rupture of an aneurysm, part of the brain malfunctions with resulting symptoms or even death.

Most strokes (80% or more) happen because the circulation to the brain is cut off and brain cells that die. These strokes are called "ischemic strokes", and many of these are caused by blockages in the carotid artery. When atherosclerotic plaque builds up in the carotid artery it produces progressively more severe blockage ("stenosis"), which ultimately results in reduced blood flow through that vessel to the brain. Pieces of the plaque loosened by turbulent blood flow may travel into the smaller arteries of the brain causing deficiency of oxygen to the brain cells and stroke symptoms. Temporary strokes (TIA's) may precede permanent strokes. These are stroke symptoms that last for only a few minutes and then disappear.

STROKE SYMPTOMS:

• Weakness, numbness, and paralysis of an arm, leg, hand, or foot
• Loss of speech function
• Slurred or garbled speech
• Loss of ability to understand speech
• Loss of vision in only one eye
• Severe unremitting headache
  

RISK FACTORS:

• Atherosclerosis
• Hypertension
• Diabetes
• Smoking
• High cholesterol levels
• Atrial Fibrillation
• Prior stroke
• Family history of stroke
  

STROKE PREVENTION: Control of risk factors - stop smoking, blood pressure reduction, regular exercise, lower cholesterol by diet and/or medication, and Aspirin. (Coumadin for patients with atrial fibrillation) Carotid surgery is beneficial for selected patients (Carotid Endarterectomy - CEA) Controlled scientific trials have shown that CEA reduces stroke in certain groups of patients.

WHAT DOES A VASCULAR SURGEON DO TO HELP PATIENTS MANAGE CAROTID ARTERY DISEASE?

Vascular surgeons have pioneered and refined ultrasound scanning for the diagnosis of carotid artery disease. The severity of a blockage can be determined without any risk or discomfort to the patient. In many cases this can eliminate the need for costlier and more risky examinations like arteriograms (catheterization procedures).

Vascular surgeons pioneered and refined carotid endarterectomy for the treatment of severe carotid artery disease. We recognized right away that this procedure reduced the risk of having a stroke, but for decades, many physicians remained skeptical. This procedure has been tested, and retested compared to all medical treatments! Now even the most skeptical would have to admit that it has been successful.

Vascular surgeons have proven that their surgery is of life-long benefit. Ultrasound scans of the carotid arteries are performed routinely after surgery. More than 90% of patients are free from stroke and have normal carotid arteries for the rest of their lives.

Vascular surgeons are now testing newer treatments like angioplasty and stent placement for treatment of severe carotid disease, to see if it will be a successful as current surgical treatments

WHO CAN BE HELPED BY CAROTID ENDARTERECTOMY?

In patients who have coincidentally been found to have carotid stenosis and have no symptoms, CEA is usually recommended if stenosis is greater than 80% depending on the patient’s condition. Those who have 70% stenosis in both carotid arteries are also considered for the surgical procedure. Patients who have TIA’s and 50% carotid stenosis also have favorable risk reduction of stroke from the operation.

The operation to remove the plaque is performed through a small incision on the side of the neck. Either general anesthesia or local anesthesia can be used to carry out the procedure. The plaque occupies the inner 2/3rds of the artery and it can be selectively removed to restore the artery to normal size. There are a variety of techniques for reconstructing the artery and these are used at the discretion of the operating vascular surgeon. Decision-making is based on the unique characteristics of each patient. At the end of the operation an ultrasound study (Duplex Scan) is used to be sure that all of the plaque has been removed and that the blood flow is normal. If everything goes well, most people can go home on the morning after surgery. There is usually very little disability related to this operation, and minimal restriction of physical activity. A number of large scientific studies have confirmed that for patients with severe carotid artery disease, CEA was 2-3 times better at preventing a stroke than the best medical treatments doctors could provide.

If you or any of your family members have carotid artery disease and are having symptoms, or if your think you might be at risk for having a stroke, for any of the reasons listed above…see your doctor and ask them.

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