Atherosclerotic Carotid Artery Disease

1. Overview

Atherosclerosis is a disease in which the wall of the artery develops abnormalities, called lesions. These lesions may lead to narrowing due to the buildup of atheromatous plaque. Initially, there are generally no symptoms. When severe, it can result in coronary artery disease, stroke, peripheral artery disease, or kidney problems, depending on which arteries are affected.

Atherosclerotic plaques begin to form in the common carotid artery, which is the main artery supply the blood flow to the brain, at 20 years of age. The plaque typically starts on the back wall of the common carotid artery. As the plaque enlarge, they encroach on the lumen of the artery, leading to sudden blood flow blockade and subsequent severe brain damage. 

2. Presentation

May present as a transient ischemic attack (TIA) or stroke with any of the following findings:

◆ Blindness of one side.

◆ Inability to move or feel on one side of the body

◆ Problems in understanding or speaking

3. Evaluation of the Extent of Carotid Disease

Doppler, CTA, or MRA are acceptable initial screening tests. In patients with an abnormal screening test, a common strategy is to obtain a second confirmatory noninvasive test to evaluate the carotid artery before intervention. The combination of carotid ultrasound and MRA has proved cost effective with good reliability. If 2 noninvasive tests are discordant, catheter angiography should be considered before intervention.

◆ Angiography: In angiography, a thin plastic tube, called a catheter, is inserted into an artery through a small incision in the skin. Once the catheter is guided to the area being examined, a contrast material is injected through the tube and images are captured using a small dose of ionizing radiation (x-rays). It is the“gold standard”test for evaluating the blood vessel constriction.

◆ Duplex Doppler ultrasound: Doppler ultrasonography measures the velocity of blood flow through the brain's blood vessels, which could help evaluate the blood vessels constriction.

Magnetic resonance angiography(MRA): Magnetic resonance angiography–also called a magnetic resonance angiogram or MRA–is a type of MRI that looks specifically at the body's blood vessels. It may obviate the need for angiography in some cases.

Computed tomography angiography(CTA): CT angiography is a test that uses X-rays to provide detailed pictures of the blood vessels that go to the brain. CTA involves ionizing radiation (X-rays) and IV iodinated contrast, limiting its use in patients with dye allergies and renal dysfunction. Results are comparable to MRA and Doppler. CTA can be performed within a few seconds and yields high-resolution images of all vessels as well as the surrounding soft tissues. 

4. Treatment Options

The goal for the management is always to prevent a stroke. The management strategy depends on the narrowing extent of the carotid artery. If the blockade of the carotid artery is mild or moderate, the strategy would be lifestyle modifications: quitting smoking, losing weight, eating healthy foods, reducing salt and exercising regularly. If the blockade of the carotid artery is severe, the strategy would be invasive surgical treatments.

◆Carotid endarterectomy

Carotid endarterectomy is surgery that removes plaque buildup from inside a carotid artery in your neck. The surgeon will make an incision, or cut, on the patient’s neck to expose the blocked section of the carotid artery. And then he will cut into the affected artery and remove the plaque through this cut. A temporary flexible tube may be inserted so blood can flow around the blocked area as the plaque is cleared. After removing the plaque from the artery, the surgeon will close the artery and neck incisions with stitches.

◆Carotid angioplasty/stenting

Carotid angioplasty with stenting is a minimally invasive procedure in which a very small hollow tube, or catheter, is advanced from a blood vessel in the groin to the carotid arteries. Once the catheter is in place, a balloon may be inflated to open the artery and a stent is placed.


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