Carotid Artery Disease

Diagram: Carotid Artery Disease
Figure A shows the location of the right carotid artery in the head and neck. Figure B is a cross-section of a normal carotid artery that has normal blood flow. Figure C shows a carotid artery that has plaque buildup and reduced blood flow.

Disease of the carotid arteries can lead to stroke. Much as narrowed arteries to the heart can cause a heart attack, narrowed arteries to the brain, can lead to a “brain attack”, commonly called a stroke. There are four arteries that deliver blood and oxygen to the brain–two in the front of the neck (Right and Left Internal Carotid Arteries) and two in the back of the neck (Right and Left Vertebral Arteries.)

As these arteries become clogged with plaque–due to genetics, high blood pressure, diabetes, high cholesterol, smoking, diabetes or a sedentary life style (to name a few reasons)–blood flow to the brain diminishes placing the brain at risk for a stroke.

Most narrowing of the carotid arteries is asymptomatic; that is, the patient has no idea that the narrowing is occurring until a stroke occurs. Sometimes, people can have a “mini-stroke” (often called a Transient Ischemic Attack or a TIA) which is a warning sign that a major stroke may be imminent. A physician–at a routine physical examination–may listen to the artery in the neck with a stethoscope. This can detect a “rumbling” sound, which might prompt further investigation. The use of ultrasound to diagnose narrowing of the carotid arteries (carotid artery stenosis) is the gold standard when performed by specialists. Treatment options vary from using medication to balloon angioplasty to surgery depending on the degree of narrowing, the symptoms and the overall health status of the person with the disease.

Diagnosis

The best way to identify a narrowing of the carotid artery is with an ultrasound examination performed by a trained Vascular Technologist.

Photo: Vascular Technologist Performing Ultrasound Examination
Vascular Technologist Performing Ultrasound Examination

The use of ultrasound technology is safe, painless and, when performed by specialists, extremely accurate in diagnosing narrowing of the carotid arteries (carotid artery stenosis.) There is not radiation exposure and no risk associated with an ultrasound examination. This technology is able to estimate an approximate range of narrowing of the carotid artery that will allow the physician to recommend the best treatment option.

Photo: Color flow ultrasound image of the carotid bifurcation. There is a minimal amount of plaque in the bulb.

Other ways to diagnose narrowing of the carotid artery may include the use of Magnetic Resonance Imaging (MRI) or Computed Tomography (CT scan.)

MRI of the arteries (referred to as Magnetic Resonance Angiography or MRA, [figure below]) can detect stenosis (narrowing) of the carotid arteries without the use of radiation exposure. It is accurate and also allows the physician to examine the brain itself, if necessary. It does require an injection into the vein to help visualize the arteries better.

Photo: Magnetic Resonance Angiography (MRA)
Magnetic Resonance Angiography (MRA)

CT Scanning of the Arteries (CTA) also provides information about the blood supply to the brain (carotid arteries and vertebral arteries.) However, this technique requires both radiation exposure and injection of contrast into the vein–both of which are safe when done by experts.

A rare technique used to diagnose carotid artery narrowing is an angiogram or arteriogram. This requires insertion of a small tube into the artery in the groin that is passed up to the neck. From there, contrast is injected into the artery and x-ray images are taken which allows the physician to see the narrowing of the carotid arteries. As the other technologies have improved, this technique is rarely used to make the diagnosis of carotid disease in the 21st century.

Treatment Overview

The treatment of carotid disease varies from administration of medication to surgical removal of the plaque that is narrowing the artery supplying blood to the brain. Differences of opinion vary as to when treatment should be instituted and what type of treatment is most appropriate.

Those with minimal narrowing of the carotid arteries (<60%) are best managed by reducing the risk factors associated with hardening of the arteries (atherosclerosis.) This includes life style modifications (smoking cessation, exercise, and dietary improvement) and appropriate management of concurrent diseases (high cholesterol, diabetes mellitus, and obesity.)

Those patients who have a narrowing greater than 60% may be managed in one of several ways depending on the associated symptoms, the exact degree of narrowing and the other medical conditions affecting the patient.

Medical Management:

The use of statin medications to control lipids is important. Additionally, the use of medicine to reduce the "stickiness" of the blood (anti-platelet drugs such as aspirin or Plavix®) is helpful in the medical management of carotid stenosis.

Diagram: Balloon Angioplasty and Stent
Fig. 5: Balloon Angioplasty and Stent

Balloon Angioplasty and Stent:

The use of a balloon to stretch the plaque within the carotid artery followed by placement of a metal stent to hold the artery open has been shown to be effective in some instances of carotid disease. The balloon is passed up over a thin wire that has been inserted from the groin crease under x-ray guidance (figure 5).

Surgery:

The use of surgery has been long-known to be safe and effective in the management of carotid disease. Through a small incision in the neck, the artery is approached, opened and the plaque scraped out returning the artery to is "normal" size.

Which Treatment Option is Best?

All three options have been shown to be effective. It is important for the physician to consider all three options as each patient may require a different approach. We, at The Cardiovascular Care Group, are well versed in all three modalities. We will recommend the treatment that is best suited for each individual patient.

Learn About the Treatment of Carotid Artery Disease
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