Carotid Artery Stenosis Treatment: Methods That Eliminate Stroke Risk
Carotid artery stenosis is one of the problems we encounter most often in my clinic and take most seriously, because the two carotid arteries supply the greater part of the brain, and a severe narrowing or a fragmenting plaque in these vessels can directly cause a stroke. In this article I will explain the different techniques we use when treating carotid artery stenosis. Why carotid stenosis develops, how we diagnose it, who we offer carotid screening programs to, what kinds of treatment we apply in carotid stenosis, and what can be done to prevent it are subjects I will cover in separate articles, both grounded in the science and explained in plain language.
What Is Carotid Artery Stenosis and Why Does It Develop?
On each side of our neck there is a main artery (the carotid artery) that carries blood to the brain. Over the years, much like limescale building up inside water pipes, a layer made of cholesterol, calcium and inflammatory cells (an atherosclerotic plaque) can accumulate on the inner surface of these vessels. In time this plaque thickens and narrows the internal diameter of the artery. The real danger lies less in the vessel becoming completely blocked than in the surface of this plaque cracking or breaking apart: if a small fragment breaks off and travels with the bloodstream to the brain, it blocks a small vessel there and causes a sudden drop in the blood supply to that region, and that is what a stroke is. Sometimes the fatty core inside these plaques comes into contact with the blood when the plaque surface ruptures, and the blood cells rapidly try to wrap up and trap this foreign material with a clot. This in turn leads to serious adverse outcomes, either through sudden blockage of the vessel supplying the brain or because the clot breaks up, or travels whole, into a cerebral artery.
Which Treatment for Which Patient?
When deciding which patient’s carotid stenosis we should treat and which patient we can continue to monitor for a while longer, we rely on the largest and most frequently cited studies in the field (the NASCET and ECST trials, together with the ACAS and ACST trials for asymptomatic patients) and on the current European Society for Vascular Surgery (ESVS) 2023 Guidelines on Carotid and Vertebral Artery Disease.
Treatment Options
Medical Therapy (Best Medical Treatment): In every patient, whether or not an interventional treatment is performed, we provide the fundamental therapies: a blood thinner (antiplatelet), a high-dose cholesterol-lowering drug (statin), blood pressure and blood sugar control, and stopping smoking. With the advances in these treatments over the past 20 years, we know that the annual risk of stroke in mild to moderate asymptomatic stenosis has fallen markedly. Carotid Endarterectomy (CEA – Open Surgery): This is the method that has been in use for decades and has the largest body of data behind it. We enter through a small incision in the neck, open the artery, clear out the plaque inside it and then close the artery again or repair it with a patch. It can be performed under general or regional (local) anesthesia and usually requires a hospital stay of 1-2 days. With correct patient selection, the stroke and death risk associated with this procedure is very low in experienced centers and hands (the guidelines define the acceptable upper limit as 6% in symptomatic patients and 3% in asymptomatic patients; we work far below these percentages, that is, with far higher success). Carotid Artery Stenting (CAS): We enter the arterial system from the groin or the neck and, with the help of a thin catheter, place a stent (a metal mesh that holds the artery open from the inside) at the site of the narrowing. It requires no incision and is usually performed under local anesthesia. Like every physician, we have known for years that carotid surgery has been found superior to carotid stenting in all the trials; nevertheless, we do prefer carotid stenting in a small and particular group of patients, especially those who have previously had surgery or radiotherapy to the neck, those at high risk for anesthesia, and those whose vascular anatomy is not suitable for surgery. Transcarotid Artery Revascularization (TCAR): In TCAR, a newer method, we enter the carotid artery directly through a very small incision in the neck and, by temporarily reversing the direction of blood flow during the procedure (flow reversal), we prevent any plaque fragments from travelling to the brain. This technique, which aims to combine the advantages of surgery and stenting, is being performed in a growing number of centers.
In short, the choice of method is decided by weighing up the patient’s age, accompanying illnesses, vascular anatomy, the imaging characteristics of the plaque and the experience of the center and the surgeon together.
The Period After the Procedure
After carotid endarterectomy we usually discharge our patients within two days. Apart from mild tenderness in the neck lasting a few days, there are no significant restrictions. After stenting or TCAR recovery is even faster; we discharge most of our patients the same day or the next day. With both methods we place the treated artery and the opposite side into a follow-up program with regular doppler ultrasound after the procedure.
Frequently Asked Questions
How is carotid artery stenosis detected before it causes symptoms? It is usually found through a bruit heard while examining the neck at a routine health check, or incidentally on imaging performed for another reason. For this reason we recommend screening doppler ultrasound for people over 50, smokers and those with cardiovascular disease.
Does every narrowing require surgery? No. The degree of narrowing and whether or not the patient has symptoms are the most important determinants. In many patients appropriate medication and regular follow-up are sufficient.
What is the difference between surgery and stenting, and which is better? Both are proven methods; which is more suitable varies from patient to patient. In general, open surgery (CEA) is the method that has been used longest, has the broadest body of data and is known to be superior; stenting comes to the fore in patients who require no incision and who are at high surgical risk.
I have had a transient ischemic attack (mini stroke); how soon should I be treated? In this situation time is highly critical. The guidelines recommend that, in suitable patients, the intervention be carried out within the first 2 weeks and if possible within the first few days, because the risk of a further stroke is highest in those early days.
Conclusion
Carotid artery stenosis is a disease that progresses silently but whose consequences can be very grave. The good news is that with the right diagnosis at the right time and the right choice of treatment, it is possible to reduce the risk of stroke to a very large extent. Whether the situation calls for follow-up with medication or for surgery or stenting, the most sound approach is for the decision to be made according to the patient’s own risk profile, together with an experienced vascular surgery team.
If a bruit has been heard in your neck, if you have persistent ringing or rushing sounds in your ear, if there is a family history of stroke, or if you have experienced any of the symptoms described above, you can book an appointment for a detailed examination and doppler ultrasound assessment.
References
- Naylor AR, Rantner B, Ancetti S, et al. European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg. 2023;65:7–111.
- North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial Effect of Carotid Endarterectomy in Symptomatic Patients with High-Grade Carotid Stenosis (NASCET). N Engl J Med. 1991;325:445–453.
- Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for Asymptomatic Carotid Artery Stenosis (ACAS). JAMA. 1995;273:1421–1428.
- Halliday A, Harrison M, Hayter E, et al. 10-Year Stroke Prevention after Successful Carotid Endarterectomy for Asymptomatic Stenosis (ACST-1). Lancet. 2010;376:1074–1084.
- Brott TG, Hobson RW 2nd, Howard G, et al. Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis (CREST). N Engl J Med. 2010;363:11–23.