What are carotid endarterectomy and carotid angioplasty with stenting ?
Carotid endarterectomy (CEA) and carotid artery angioplasty with stenting (CAS) are procedures performed to treat carotid artery disease in certain circumstances. Carotid artery disease, also called carotid artery stenosis, occurs when the carotid arteries, the main blood vessels that carry oxygenated blood to the brain, become narrowed.
Narrowing of the carotid arteries is most commonly related to atherosclerosis (a build-up of plaque, which is a deposit of fatty substances, cholesterol, cellular waste products, calcium, and fibrin in the inner lining of an artery). Atherosclerosis, or "hardening of the arteries," is a vascular disease (disease of the arteries and veins). Carotid artery disease is similar to coronary artery disease, in which blockages occur in the arteries of the heart, and may cause a heart attack.
It is unknown exactly how atherosclerosis begins or what causes it. Atherosclerosis is a slow, progressive, vascular disease that may start as early as childhood. However, the disease has the potential to progress rapidly. It is generally characterized by the accumulation of fatty deposits along the innermost layer of the arteries. If the disease process progresses, plaque formation may take place.
This thickening narrows the arteries and can decrease blood flow or completely block the flow of blood to the brain.To better understand how carotid artery disease affects the brain, a basic review of the anatomy of the circulation system of the brain follows.
What are the carotid arteries ?
The main supply of blood to the brain is carried by the carotid arteries. The carotid arteries branch off from the aorta (the largest artery in the body) a short distance from the heart, and extend upward through the neck carrying oxygen-rich blood to the brain.
There are four carotid arteries: the right and left internal carotid arteries and the right and left external carotid arteries. One pair (external and internal) is located on each side of the neck. Just as a pulse can be felt in the wrists, a pulse can also be felt on either side of the neck over the carotid arteries.
Why are the carotid arteries important ?
Because the carotid arteries deliver blood to the brain, carotid artery disease can have serious implications by reducing the flow of oxygen and nutrients to the brain. The brain needs a constant supply of oxygen and nutrients in order to function. Even a brief interruption in blood supply can cause problems.
Brain cells begin to die after just a few minutes without blood or oxygen. If the narrowing of the carotid arteries becomes severe enough to block blood flow, or a piece of atherosclerotic plaque breaks off and obstructs blood flow to the brain, a stroke may occur.
How could this cause a stroke or mini-stroke ?
Carotid artery disease can cause a stroke in two main ways : -
The narrowing of the artery becomes so bad that it blocks off the artery completely. In some people, especially if another carotid artery is also blocked or semi-blocked, this can limit the blood supply to the brain causing a stroke. This type of stroke is called a haemodynamic stroke.
When a blood clot forms on the roughened surface of the narrowing. This blood clot can then break off and block one or more brain arteries. This type of stroke is called an embolic stroke. The severity of the stroke depends on how big the blood clot was and which artery in the brain is affected.
Carotid Artery Disease Treatment
There are two procedures used to treat carotid artery disease. The standard surgical procedure is carotid endarterectomy (CEA), while the newer minimally invasive endovascular intervention is called carotid artery angioplasty with stenting (CAS).
carotid endarterectomy
In a carotid endarterectomy, atherosclerotic plaque that has built up on the inside of the carotid artery wall is surgically removed. An incision is made on the side of the neck where the affected carotid artery is located.
Under direct visualization, the artery is opened and the plaque removed. The artery is sutured back together, restoring normal blood flow to the brain. This procedure may be performed while a patient remains awake under local anesthesia or while the patient is asleep under general anesthesia.
carotid artery angioplasty with stenting (CAS)
Carotid artery angioplasty with stenting (CAS) is a minimally invasive procedure requiring only a small incision in the groin. A special catheter (long hollow tube) is inserted into the carotid artery to be treated.
This catheter has a tiny balloon at its tip. The balloon is inflated once the catheter has been placed into the narrowed area of the carotid artery. The inflation of the balloon compresses the fatty tissue in the artery and makes a larger opening inside the artery for improved blood flow.
A stent (a tiny, expandable metal coil) may be inserted into the newly-opened area of the artery to help keep the artery from narrowing or closing again.
Because of the potential for clots (emboli) to dislodge from the plaque into the circulation of the brain and possibly cause a stroke, there are now devices called embolic prevention devices (EPD) being used during CAS.
One type of EPD has a filter-like basket attached to a catheter that is positioned in the artery so as to "catch" any clots or small debris that might break loose from the plaque during the procedure. This technique may help reduce the incidence of stroke during carotid angioplasty.
Your physician will determine the most appropriate intervention for treating your carotid artery disease. Other related procedures that may be used to diagnose carotid artery disease include carotid artery duplex scan and cerebral arteriogram. Please see these procedures for additional information.
Carotid Endarterectomy or Carotid artery Angioplasty with Stenting ?
Carotid endarterectomy may be performed to treat a blockage or narrowing of the carotid arteries, thus improving blood supply to the brain. Carotid endarterectomy has been shown to be effective for preventing stroke in carotid artery disease.
Carotid artery angioplasty with stenting (CAS) is a procedure currently being used on selected patients who are at high risk for surgery. While this procedure is performed widely, the long-term effects are still being studied.
High risk conditions under which CAS may be considered include, but are not limited to, the following : -
older age
coronary artery disease or pending open heart surgery
heart failure
heart valve disease
heart arrhythmias
angina or heart attack within the last 6 months
cancer
carotid artery disease in more than one carotid artery
location of the blockage in the carotid artery
carotid artery stenosis (narrowing) caused by radiation, previous surgery on the neck, or severe chronic obstructive pulmonary disease (COPD)
Carotid artery disease may be asymptomatic (without symptoms) or symptomatic (with symptoms). Asymptomatic carotid disease is the presence of a significant amount of atherosclerotic plaque build-up in the carotid arteries without obstructing blood flow enough to cause symptoms. Symptomatic carotid artery disease may result in either a transient ischemic attack (TIA) and/or a stroke (brain attack).
The decision to treat carotid artery disease is based on certain criteria such as, but not limited to, the following : -
Symptomatic and asymptomatic carotid artery disease with blockage greater than 70 percent in the internal carotid artery is usually treated surgically.
Asymptomatic and symptomatic carotid artery disease with blockage of 50 percent to 69 percent (with results from diagnostic tests indicating blockage closer to 69 percent) may require surgical treatment. Risk factors associated with carotid artery disease are taken under consideration when determining the need for surgery.
Asymptomatic and symptomatic carotid artery disease with blockage of 50 percent to 69 percent (and results of diagnostic tests indicating blockage closer to 50 percent) may be treated medically, depending on the individual situation.
Asymptomatic and symptomatic carotid artery disease with blockage of less than 50 percent are generally treated medically.
Choice of treatment such as carotid endarterectomy, carotid artery angioplasty with stenting, or medical treatment will be determined by your physician. There may be other reasons for your physician to recommend a carotid endarterectomy or carotid artery angioplasty with stenting.
During the Procedure
Both carotid endarterectomy and carotid angioplasty with stenting require a stay in hospital. Procedures may vary depending on your condition and your physician's practices.
Carotid endarterectomy
Generally, carotid endarterectomy (CEA) follows this process : -
An intravenous (IV) line will be started in your arm or hand. An additional catheter will be inserted in your wrist to monitor your blood pressure, as well as for obtaining blood samples. One or more additional catheters may be inserted into your neck, opposite the surgery site, to monitor your heart function. Alternate sites for the additional catheter include the subclavian (under the collarbone) area and the groin.
You will be positioned on the operating table, lying on your back, with your head raised slightly and turned away from the side to be operated on.
A catheter will be inserted into your bladder to drain urine.
The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
CEA may be performed under local anesthesia. You will be sleepy, but will not feel the area being operated on. You will receive a sedative medication in your IV before the procedure to help you relax. However, you will remain awake, but sleepy, during the procedure. This allows the physician to monitor how you are doing during the procedure by asking you questions and testing your hand grip strength.
If the CEA is performed under local anesthesia, the physician will provide constant support and keep you comfortable during the procedure. Pain medicine will be administered.
Under local anesthesia, you will receive oxygen through a nasal cannula, a tube that fits in your nose.
A CEA may also be performed under general anesthesia (you will be asleep). Once you are sedated, a breathing tube will be inserted through your throat into your lungs. You will be connected to a ventilator, which will breathe for you during the procedure.
You will be given a dose of antibiotics through your IV to help prevent infection.
The skin over the surgical site will be cleansed with an antiseptic solution.
The physician will make an incision (cut) down the side of the neck over the diseased artery. Once the carotid artery is exposed, the physician will make an incision into the artery.
The physician may use a device called a shunt to divert blood flow around the surgical area to maintain blood flow to the brain. A shunt is a small tube that is inserted into the carotid artery to deliver blood flow around the area being operated on.
With the blood flow diverted, the physician will remove the atherosclerotic plaque from the artery.
The shunt will be removed and the artery will be closed. The incision in the neck will be sutured together.
A drain may be placed in your neck. The drain is a small tube that is inserted in the neck area to drain any accumulation of blood into a small palm-size suction bulb. It is generally removed the morning after the procedure.
You may receive blood pressure medication through your IV during and after the procedure to keep your blood pressure within a certain range.
If you received general anesthesia, the physician will wake you up in the operating room to be sure you can respond to questions.
A sterile bandage/dressing will be applied.
Carotid angioplasty with stenting (CAS)
After the Procedure
In the hospital
After the procedure you will be taken to the recovery room for observation. Once your blood pressure, pulse, and breathing are stable and you are alert, you may be taken to the intensive care unit (ICU) or your hospital room in India.
At the appropriate time, you will be assisted out of bed to walk around as tolerated.
If a drainage tube was placed in the incision during the procedure, it most likely will be removed the next morning by your physician.
Your diet will be advanced to solid foods as tolerated. Take a pain reliever for soreness as recommended by your physician. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications.
Your physician may schedule you for follow-up duplex ultrasound procedures to monitor the carotid arteries in your neck for a period of time.
Generally, patients are able to go home / hotel within one to two days following a carotid endarterectomy in India and fly back to their country in weeks time.
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