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Angioplasty and stent placement - carotid artery

Definition

You have an artery on each side of your neck called the carotid artery. This artery brings needed blood to your brain and face.

The blood flow in this artery can become partly or totally blocked by fatty material called plaque. A partial blockage is called carotid artery stenosis (narrowing). A blockage in your carotid artery can reduce the blood supply to your brain. A stroke can occur if your brain does not get enough blood.

There are two invasive ways to treat a carotid artery that is narrowed or blocked. One is surgery called endarterectomy. The other is a procedure called carotid angioplasty with stent placement.

Carotid angioplasty and stenting (CAS) is done through a much smaller incision, by pushing instruments into your arteries:

  • Your surgeon will make a surgical cut in your groin after using some numbing medicine. You will also be given medicine to relax you.
  • Your surgeon will insert a catheter (a flexible tube) through the cut into an artery. The doctor will carefully guide the catheter up to your neck to the blockage in your carotid artery.
  • Your surgeon will use live x-ray pictures to see your artery. This kind of x-ray is called fluoroscopy.
  • Next your surgeon will pass a guide wire through the catheter to the blockage. Another catheter with a very small balloon on the end will be pushed over the guide wire and into the blockage. Then the balloon will be blown up. The balloon presses against the inside wall of your artery. This opens the artery and restores proper blood flow to your brain.
  • A stent (a wire mesh tube) may also be placed in the blocked area. The stent is inserted at the same time as the balloon catheter. It expands when the balloon is blown up. The stent is left in place to help keep the artery open. The surgeon then removes the balloon.

Alternative Names

Carotid endarterectomy; CEA; Carotid angioplasty and stenting; CAS; Endarterectomy - carotid artery; Angioplasty - carotid artery; Percutaneous transluminal angioplasty - carotid artery; PTA - carotid artery; Angioplasty - carotid artery

Description

Narrowing or blockage of your carotid arteries increases the risk that you may have a stroke. Carotid angioplasty and stenting is one of several treatments for this blockage.

There are several ways your doctor may know you have narrowing or blockage in your carotid artery. Two common ones are:

  • You may have had symptoms of a stroke or a transient ischemic attack (TIA, also called a mini-stroke). Some of these symptoms are weakness, blurred vision, confusion, or slurred speech.
  • You may not have any symptoms, but your doctor may find a problem during a physical exam. Your doctor may hear something called a bruit when using a stethoscope to listen to your blood flow. A bruit is an abnormal, wind-like sound in your artery.

Your doctor will need to do one or more tests to see how blocked one or both of your carotid arteries are.

Treatment options that do not involve surgery, which your doctor will discuss with you are:

  • No treatment, other than checking your carotid artery with tests every year
  • Medicine and diet to lower your cholesterol
  • Tests to check your carotid artery and blood-thinning medicines to lower your risk of stroke. Some of these medicines are aspirin, clopidogrel (Plavix), and warfarin (Coumadin).

Surgery or angioplasty to remove the buildup in your carotid artery may be done if the carotid artery is narrowed by more than 70%, or if the narrowing is between 50% and 70% and your doctor feels that you are at high risk of having a stroke.

Carotid surgery (endarterectomy) is a safe surgery and is often the first invasive choice to treat carotid artery narrowing.

If you have had a stroke, your doctor will consider whether treating your blocked artery with surgery is safe for you. Your doctor will compare your risk of having another stroke if you do not have surgery with the risk of having serious problems from the surgery itself.

Carotid angioplasty and stenting is more likely to be used when carotid endarterectomy would not be safe.

Why the Procedure Is Performed

Arteries can become narrowed or blocked by deposits called plaque. Plaque is made up of fat and cholesterol that builds up on the inside of the artery walls. This condition is called atherosclerosis.

Angioplasty may be used to treat:

  • Persistent chest pain (angina) that medicines do not control
  • Blockage of one or more coronary arteries that puts you at risk for a heart attack
  • Blockage in a coronary artery during or after a heart attack

Not every blockage can be treated with angioplasty. Some patients who have many blockages or blockages in certain locations may need a coronary bypass (heart surgery).

Risks

The risks for any anesthesia are:

The risks for any surgery are:

Risks of carotid surgery are:

  • Allergic reaction to dye (only with carotid artery angioplasty)
  • Blood clots or bleeding in the brain at the site of surgery
  • Brain damage
  • Heart attack
  • More blockage of the carotid artery over time
  • Seizures (this is rare)
  • Stroke (this is rare)

Before the Procedure

Your doctor will do a thorough physical exam and several medical tests.

Always tell your doctor or nurse what drugs you are taking, even drugs, supplements, or herbs you bought without a prescription.

During the 2 weeks before your surgery:

  • Days before the surgery, you may have to stop taking drugs that make it harder for your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), clopidogrel (Plavix), naprosyn (Aleve, Naproxen), and other drugs like these.
  • Ask your doctor which drugs you should still take on the day of your surgery.
  • If you smoke, you need to stop. Ask your doctor or nurse for help quitting.
  • Always let your doctor know about any cold, flu, fever, herpes breakout, or other illness you may have before your surgery.

Do NOT drink anything after midnight the night before your surgery, including water.

On the day of your surgery:

  • Take the drugs your doctor told you to take with a small sip of water.
  • Your doctor or nurse will tell you when to arrive at the hospital.

After the Procedure

You may have a drain in your neck that goes into your surgical cut. It will drain fluid that builds up in the area. It will be removed within a day.

After surgery, your doctor may want you to stay in the hospital overnight so that nurses can watch you for any signs of bleeding, stroke, or poor blood flow to your brain. You may be able to go home the same day if your procedure is done early in the day and you are doing well.

Outlook (Prognosis)

Carotid artery surgery may help lower your chance of having a stroke. But you will need to make lifestyle changes to help prevent plaque buildup, blood clots, and other problems in your carotid arteries over time. You may need to change your diet and start an exercise program, if your doctor tells you exercise is safe for you.

References

International Carotid Stenting Study Investigators. Dobson EJ, Featherstone RL, Bonati LH, van der Worp HB, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet. 2010;375:985-997.

Goldstein LB. Prevention and management of stroke. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa: W.B. Saunders; 2007:chap 58.

Mas JL, Chatellier G, Beyssen B, Branchereau A, Moulin T, Becquemin JP, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355(16):1660-1671.

Eckstein HH, Ringleb P, Allenberg JR, et al. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Lancet Neurol. 2008;7(10):893-902.

Adams RJ, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB, et al. Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2008;39:1647-1652.


Review Date: 7/10/2010
Reviewed By: Luc Jasmin, MD, PhD, Department of Neurosurgery, Cedars Sinai Medical Center, Los Angeles, and Department of Anatomy, University of California, San Francisco, CA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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