Health Matters: Minimally Invasive Procedure Gets Blood Flowing Again, Reduces Stroke Risk

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By Elliot Sambol, MD, FACS

Did you know that up to one third of all strokes in the United States are caused by a condition called carotid artery stenosis?

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Carotid artery stenosis — also referred to as carotid artery disease — results from a blockage or narrowing of the carotid arteries, the two major blood vessels on either side of your neck that provide your brain’s blood supply.

While there are usually no symptoms of carotid artery stenosis until a stroke occurs, once diagnosed it can be treated to reduce your risk and prevent future strokes.

Penn Medicine Princeton Health offers a variety of options for treating carotid artery stenosis, including transcarotid artery revascularization (TCAR), a minimally invasive procedure that can clear blockages and open a narrowed carotid artery to restore blood flow.

What Causes Carotid Artery Disease? 

Carotid artery disease is typically caused by atherosclerosis, which is the hardening and narrowing of the arteries due to the buildup of fatty deposits called plaque.

Plaque can slowly squeeze the artery closed, reducing blood flow. Or a blood clot may suddenly form, blocking some or all of the blood flow to your brain. If the clot closes the artery completely, you may have a stroke.

Risk factors for carotid artery disease include:

• Diabetes.
• Family history of stroke.
• High blood pressure, high cholesterol, or high triglycerides.
• Older age, especially if you are male.
• Smoking or using alcohol or recreational drugs.
• Trauma to your neck.

What are the Symptoms?

Carotid artery disease typically does not cause symptoms in its early stages. In some instances, your doctor may notice a sound called a “bruit” when listening to your pulse. This faint whistling sound is a distinctive sign of a blocked carotid artery.

As carotid artery stenosis advances, the first sign may be a transient ischemic attack (TIA) commonly called a mini stroke. For some people, a stroke is the first sign.

Signs of a stroke and TIA include:

• Blurred vision or vision loss.
• Confusion.
• Memory loss.
• Numbness or weakness in part of your body or one side of your body.
• Problems with thinking, reasoning, memory, and speech.

If you think that you or someone you know is having a stroke or TIA, call 911. Seeking immediate medical care can reduce the chance of long-term damage.

How is Carotid Artery Disease Diagnosed and Treated?

Diagnosis of carotid artery disease usually begins with a physical exam. Your doctor will listen to the blood flow in your neck for a bruit. In addition, your doctor may order imaging tests such as a CAT scan or an ultrasound to look for blockages and check how your blood flows through the carotid artery.

If carotid artery disease is diagnosed, your doctor may recommend medications to prevent blood clots and treat high cholesterol. They may also recommend healthy lifestyle practices such as not smoking, exercising, and eating a healthy diet that’s low in saturated fats.

In addition, there are a variety of surgical options to treat carotid stenosis including:

• Carotid endarterectomy, a traditional open approach that involves an incision along the carotid artery. Carotid endarterectomy has been the gold standard for the past 50 years, though it does carry risks such as cranial nerve injury, infection, and myocardial infarction (heart attack).

• Transfemoral stenting, a minimally invasive approach in which surgeons place a stent in the carotid artery, which they access through the femoral artery in the groin. With transfemoral stenting there is a risk for a stroke occurring during the operation due to the need to cross the aortic arch — the top part of the main artery carrying blood from the heart — and the risk of a plaque breaking off and traveling to the brain.

• Transcarotid artery revascularization (TCAR), a minimally invasive procedure that allows for placement of a stent within the carotid artery but avoids access from the femoral artery. This enables surgeons to avoid the inherent risks of traversing the aortic arch.

How is TCAR Performed?

With TCAR, surgeons access the carotid artery by making an incision at the base of the neck allowing for direct exposure to the artery.

During the procedure, the surgical team reverses blood flow in the area of the blockage. This reversal decreases the risk of stroke as the surgeon uses a surgical balloon and stents to reopen the narrowed artery. Blood still reaches your brain through other blood vessels.

Candidates for TCAR are typically patients who are at high risk for complications from open surgery. However, the Centers for Medicare and Medicaid Services has approved TCAR for even standard risk patients.

You may be a good candidate for TCAR if:

• You are age 80 years or older.
• Have congestive heart failure or unstable angina.
• Have kidney disease.
• Have had a heart attack within the past six weeks.
• Have a history of head or neck surgery or radiation.
• Have other problems with your larynx (voice box) or neck.
• Have carotid stenosis that returns after surgery or stenosis in both carotid arteries.
• Have uncontrolled diabetes or severe lung disease.
• Have possible scar tissue from prior surgeries.
• Have anatomic concerns such as thick neck or obesity.

The majority of patients who undergo TCAR receive general anesthesia during the procedure, and most go home the next day.

If you have been diagnosed with carotid artery disease, be sure to talk with a vascular surgeon about all your treatment options, including TCAR, which can reduce your risk for stroke by getting your blood flowing again.

To find a physician affiliated with Penn Medicine Princeton Health, call 888-742-7496, or visit www.princetonhcs.org.

Elliot Sambol, MD, FACS, is a board certified vascular surgeon and a member of the Medical Staff at Penn Medicine Princeton Health.

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