Carotid Artery Disease
February 17, 2009
Cleveland_Clinic_Host: Daniel Clair, MD, is Chairman of the Department of Vascular Surgery at Cleveland Clinic. Dr. Clair is board-certified in general and vascular surgery. He specializes in carotid artery surgery, thoraco-abdominal aortic repair/reconstruction, thoracic aortic aneurysm repair, abdominal aortic aneurysm repair, peripheral artery/vein repair/bypass surgery, aortic aneurysm stent repair and endovascular stent repair.
Welcome to our Online Health Chat with Daniel Clair, MD. We are very excited to have Dr. Clair here today for this chat. Welcome Dr. Clair! Thanks for being here!
Speaker_-_Dr__Daniel_Clair: Thanks for having me today. I am happy to be here and answer your questions.
Carotid Artery Disease - Symptoms
rpsclinic: I have 15-20 minute visual blurring in center of eye. Becoming more frequent (twice week). Ophthalmologist thinks it is octugal migraine. Any help? Thanks.
Speaker_-_Dr__Daniel_Clair: Visual blurring in the center of the eye is of significant concern because of its relationship to the visual acuity in that eye. Before simply ascribing this to ocular migraines, I would recommend that an evaluation of potential other sources of visual disturbance be assessed. Visual disturbances like this can be caused by embolization or vasculitis. Most commonly in this situation, we would obtain an echocardiogram, a carotid duplex assessment to assess potential causes of embolization. In addition, we would likely assess for vasculitis with an assessment of inflammatory markers in the blood. Finally, I would recommend a neuro-ophthalmologic evaluation to assess the cause of the headaches, the underlying etiology of the blurred vision and the potential for treatment to reduce the frequency of these as occurrence of these episodes can ultimately lead to vision loss within the eye. Most of this care can be coordinated through the offices of a vascular surgeon to assure that you get full assessment of the causes of this problem.
Ramie: Does everyone who has a carotid bruit have carotid disease?
Speaker_-_Dr__Daniel_Clair: Carotid bruits are generated from turbulent flow within the vessel. This can occur with narrowing, but can also happen at branch points or at areas of tortuosity (or where the vessels bends or curves). Carotid bruit does not mean you have carotid disease.
PLure: My husband has been having neck pain on one side of his neck. Sometimes over the years he has had dizziness but I think that is from his blood pressure medications. Is neck pain a sign of carotid artery disease?
Speaker_-_Dr__Daniel_Clair: No, carotid artery disease does not cause pain. This is important because you can have severe carotid artery disease without an warning signs. You should discuss with your doctor whether he feels you should be assessed for carotid artery narrowing. This depends upon your overall cardiovascular risk and potentially the risk of TIA or stroke being due to carotid disease.
Carotid Artery Disease - Diagnostic Tests
AnnieM3: What is the best tests for carotid artery disease?
Speaker_-_Dr__Daniel_Clair: The best screening test to look for carotid artery narrowing is carotid duplex ultrasound. This is non-invasive and essentially no risk to the patient. To confirm this, either CT angiography or MR angiography are other good ways to assess the carotid arteries. Direct angiography can provide information when the other test are inconclusive.
tim145: What does calcifications in the internal carotid arteries?
Speaker_-_Dr__Daniel_Clair: I am assuming you mean, what does this mean? Calcification implies the presence of atherosclerosis, or blockage with the carotid artery. Calcium does not necessarily imply a significant degree of narrowing, simply that narrowing is present.
RFT: Last week I had a carotid echo. They said the test came out fine but something about poor flow? Can you have poor flow and a normal test?
Speaker_-_Dr__Daniel_Clair: Those findings sound to me contradictory. This might be the setting where an additional test like CT or MR angiography might be helpful. It sounds like you should have an evaluation by a vascular specialist.
Carotid Artery Disease - 100% Percent Blockage
boyhowdy44: My right main carotid is 100% blocked. My left main is 50% blocked. your thoughts on the left?
Speaker_-_Dr__Daniel_Clair: If this was determined by ultrasound, there is a chance, about 20%, that the estimation of narrowing is more than it really is.
In most instances, I would recommend continued observation with aggressive medical therapy that should include, aspirin and statin therapy and careful monitoring of your blood pressure and lipids.
John39: I had a stroke a couple months ago – I have some weakness on my right side – they found that one of my carotid arteries are completely blocked. Is it still worthwhile to have it treated?
Speaker_-_Dr__Daniel_Clair: As a noted in several other answers, the best treatment for complete occlusion of a carotid artery is medical therapy with continued evaluation to insure the other carotid artery stays disease free.
SteveMa: I have 100% blockage in the right carotid. My left carotid is narrow too. What is the % narrowing that they do surgery on – how much does it need to be narrow and then – how do they treat a 100% blockage.
Speaker_-_Dr__Daniel_Clair: Complete occlusion is usually managed medically. The reason for this is while we can open the artery with surgery, the risk of the artery closing or causing a stroke is higher than the risk of leaving the artery alone. With a high-grade narrowing on the other side, your risk can be by carotid revascularization and most would recommend intervention at a 70% blockage or more. In this setting, the degree of narrowing should be confirmed by 2 studies. For example ultrasound and CT angiogram.
willow: My husband was just diagnosed with carotid blockage of 90 percent. What are his options? How fast do we need this done?
Speaker_-_Dr__Daniel_Clair: His options include: standard surgical therapy, or carotid endarterectomy, carotid stenting, or potentially medical therapy. If he does not have symptoms (stroke or TIA) then the evaluation and treatment of this is not an emergency and should be performed in such a way that you have your questions answered regarding all forms of therapy and can make an educated decision about what to do.
Carotid Artery Dissection
TJ: My uncle had a dissection of one of his carotid arteries. What is the likelihood of that occurring again?
Speaker_-_Dr__Daniel_Clair: Carotid dissections rarely reoccur.
RussHet: My dad is 87 years old. He went to the doctor for dizziness but the doctor said he was too old for surgery even though his carotid is 90% blocked. Is he a candidate for carotid stenting?
Speaker_-_Dr__Daniel_Clair: He maybe a candidate for carotid stenting. If he is active and reasonably healthy then carotid revascularization by one method or the other may be indicated. It is helpful to have your father evaluated by a physician who can give him an opinion regarding surgery, stenting, and medical therapy and who can also help you to make the decision regarding what form of care is most appropriate.
Carotid Artery Disease - Surgery
Edward_M_: How do you know a vascular surgeon is good?
Speaker_-_Dr__Daniel_Clair: This is a good question. You should assure that your surgeon in board certified in vascular surgery, and that the treatment of vascular disease is the primary focus of his/her practice. The Society for Vascular Surgery is comprised of vascular surgeons who have significant experience and a professional reputation which establishes them as competent and successful.
Kim: My uncle has right carotid blockage and needs surgery. In his pre surgery exams they found he had ischemia on a stress test and now they have scheduled a cath. If it turns out if he has heart blockage – how does that work – do they do both surgeries at the same time? If not, which one do they do first?
Speaker_-_Dr__Daniel_Clair: This is a complex question about a difficult patient issue. In many instances the coronary disease may be treatable with angioplasty and stent, thus allowing a decision regarding surgery or stenting for the carotid artery. If the coronary disease needs open heart surgery, the situation becomes a bit more complex and may involve either combine carotid and heart surgery or carotid stenting prior to open heart surgery. The information from your uncle's heart cath. will be important in making this decision. Hopefully his doctors will be able to present him with a clear understanding of his options, so a good decision regarding treatment can be made.
Melissa: My husband had carotid surgery a couple weeks ago. What is the long term care for that? Should he be on certain medications?
Speaker_-_Dr__Daniel_Clair: I would hope your doctor would discuss this with you personally. However there are likely 3 medical therapies he should be on long term. These include: aspirin, statin medication for lipid control and adequate blood pressure medication.
salina: Can you explain the traditional surgical approach for carotid blockages and the new minimally invasive approaches? How is the decision made on which approach to use?
Speaker_-_Dr__Daniel_Clair: This is a question has an extensive answer, but I will try to summarize. Carotid endarterectomy is the standard surgical procedure for carotid narrowing and involves a 2 to 3" incision on the neck. The artery is opened, the plaque removed and the artery repaired in a way to reduce recurrent narrowing.
Carotid stenting is performed through a groin puncture and using this approach wires and small catheters are used to open the narrowing. A stent is inserted to push the plaque out of the way and keep the artery open. Both of these procedures take between 1 and 2 hours to perform and in both instances normally require hospitalization for 1 night.
Many things influence the decision to choose one of the other. If you have carotid disease it is important that you consult with a physician who can give you information regarding both of these options to help make an educated decision on how to treat your disease.
JRsile: I had a carotid endarterectomy performed 6 years ago. What are the chances that I will ever have to do this again?
Speaker_-_Dr__Daniel_Clair: The recurrence rate for restenosis after surgery is about 5%-10% over the next 10 years. The odds are that you will never need this done again. You should clear by followed however regularly to assure there is no reoccurrence and to assess your other carotid artery.
Standard heart healthy activities, diet and medications can help to reduce the risk
JenniferJ: Why is the approach different for blocked arteries in the neck, versus blocked arteries in the heart (where they inflate a balloon to fix the blockage)?
Speaker_-_Dr__Daniel_Clair: Blocked arteries in the neck occur over a much longer length. Attempts to open them have been successful, however because the artery is irregular over a very long distance there is an increase risk of stroke compared with medical therapy alone and observation of the occlusion. Ideally, we would identify people with narrowing before they get occlusion, so we can fix the artery and reduce their risk.
matt: I you are operating on and the arteries leading to the brain, how does the brain get the blood it needs?
Speaker_-_Dr__Daniel_Clair: There are 4 arteries that supply blood flow to the brain and they all interconnect. When blood flow is stopped through one of them, the other 3 supply that region through these connects. In instances where the connections are incomplete, we can place a shunt or plastic tube to carry blood around the area we have blocked.
Carotid Artery Disease - Risk Factors
trimedic: What are the risk factors for carotid artery disease? Are some people more likely to get it than others?
Speaker_-_Dr__Daniel_Clair: The risk factors for carotid artery disease are very similar to those for coronary artery disease and include: smoking, high blood pressure, elevated cholesterol, poor diet, inactivity, family history of atherosclerosis or carotid disease. There are clearly people who are at higher risk, specifically those with significant number of the mentioned risk factors.
Beverly: My mom had carotid surgery a couple years ago. Should she also watch her cholesterol like if you have coronary artery disease?
Speaker_-_Dr__Daniel_Clair: Yes, carotid artery disease and coronary disease have a strong relationship to cholesterol and each other. Keeping your cholesterol low reduces your risk of heart attack, stroke and other cardiovascular disease.
High Blood Pressure
324_Tricia: I have high blood pressure. I had a stroke about 11 years ago. I am trying to control it but it has been difficult. What type of testing should I do to make sure I don’t have another stroke?
Speaker_-_Dr__Daniel_Clair: Daily home blood pressure monitoring can be effective in assuring good blood pressure control and decrease risk of stroke, if your stroke was due to high blood pressure. There are many other causes of stroke and in order to reduce your risk you need to have clear identification of what caused the stroke.
Transient Ischemic Attack (TIA)
JohnS: The question I have is-I have had several TIAs-what should I do to minimize the chance(s) of another TIA? I also have Type 2 diabetes-What precautions should I follow?
Speaker_-_Dr__Daniel_Clair: In order to minimize your change of TIAs, it is imperative that the underlying etiology of the TIAs be understood. If these are embolic in nature, then anti-embolic therapy potentially direct attention to the embolic source would be necessary. If these are due to hypertension, then clearly better control of the hypertension would be in order as well. My impression from your question is that you seek the input of a vascular specialist to try and identify exactly the cause of these TIAs so that you can go about treatment to reduce the risk of recurrent TIA or even potentially more significantly, a stroke in this setting.
val_KS: If you have carotid artery disease and have TIAs – what should your blood pressure be? What is goal?
Speaker_-_Dr__Daniel_Clair: If you TIAs that are thought to be due to carotid artery disease, you should have your carotid artery repaired. The risk of stroke with TIAs from carotid artery disease is on the order of 25%-30% over the next 18 months. This can be reduced dramatically by treating the artery narrowing.
Blood pressure goals for preventing progression of carotid disease are similar to those for preventing progression of heart disease and plaque build up elsewhere. Ideally, the upper number should be below 120-140 and the lower number below 80.
Fibromuscular dysplasia (FMD)
chawki2_2: i have fmd in carotid one side completely closed other side has aneurysm,what type dr would I go to see if fmd is anywhere else?
Speaker_-_Dr__Daniel_Clair: Fibromuscular dysplasia is a disease which can affect not only the carotid arteries but the renal arteries, the visceral arteries and the lower extremity arteries. In order to assess your overall risk for having fibromuscular dysplasia in other areas, the best individual to see is a vascular specialist. In some areas, this would be a Vascular surgeon, in some areas this would be a Vascular Medicine physician. Here, were have a clinic devoted especially to this disease run by one of our Vascular Medicine physicians who can see, evaluate and treat patients with fibromuscular dysplasia in conjunction with surgical input for treatment of the disease as well. This combination of a medical and surgical approach to the disease provides in my estimation, the best standpoint, the best options available for treating patients with this disease.
medicalid: I have been diagnosed with PMR & GCA and take 40 MG of Prednisone daily; still having tingling and numbness in left foot and 3 right fingers, dizziness, double vision,and now I have a bump on my forehead at the hairline; does that mean that the dose of cortisone is not high enough, should I be concerned, should I do an MRI to see what is happening with the blood vessels in my neck and head and finally could severe disc degeneration (l-1 to S-1) & dissection bring on these problems? I would be so appreciative if you could answer these questions
Speaker_-_Dr__Daniel_Clair: It sounds like from your description of the symptoms that you are having, that you have significant neurologic dysfunction intermittently that has potentially been related to your polymyalgia rheumatica and giant cell arteritis. While Cortisone or Prednisone is one of the treatments for both of these conditions, it is imperative that the disease be brought under control prior to anything further being done. Medications can be added to the steroids in order to help bring this issues under control and to reduce the symptomatology that you are having. I do think that you should seek evaluation by a Rheumatologist for these conditions to try and alleviate the problems. Again, this type of care can be coordinated through the offices of a vascular surgeon or a Vascular Medicine specialist but it is my own impression that you will likely need the input of a Rheumatologist in order to get a better assessment of the treatment options available to you. You had finally asked whether this could be due to severe disk degeneration. The disk degeneration could explain some of the symptoms you have but clearly can not explain the dizziness, double vision or the bump on the forehead. I do think that given your symptomatology that you should move forward with obtaining this opinion because I think you leave yourself at significant risk without getting these episodes under control.
Carotid Body Tumor
jkl: What is a carotid body tumor?
Speaker_-_Dr__Daniel_Clair: There is a nerve impulse center at the branching of the carotid artery that controls, blood pressure and heart rate, in rare instances this center can develop a growth. This impulse center is called the carotid body and therefore a growth here is called a carotid body tumor. These are usually benign but can be locally aggressive or malignant Most people would recommend resection of these when identified. They can run in families and genetic testing can be done for this.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Clair is now over. Thank you again Dr. Clair, for taking the time to answer our questions today.
Speaker_-_Dr__Daniel_Clair: Thank you for having me.
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