Live Web Chat Transcript:
September 12, 2007
More information:
Cleveland_Clinic_Host: Welcome Dr. Clair and thank you for being with us today. Let's begin!
Speaker_-_Dr__Clair: Thank you for having me.
Carotid Artery Disease Symptoms
Mary08: I was questioning some unusual symptoms I had had today, and wondered if I should be concerned: I had lost my bottom field of vision for about 3 minutes, and began seeing "lightning streaks" across the top left of my left eye. I sat down and closed my eyes, and the symptoms subsided. There was no dizziness or any other unusual feeling. What in the world was it? Should I seek out an ophthalmologist or a physician??
Speaker_-_Dr__Clair: Yes you should see a physician. I would recommend either an emergent visit to your physician of if you can't see your physician, you should go to the emergency room. There a couple things this could be from: All of which would require emergent attention.
mother: Recently I have been experiencing pain in the base of my skull sometimes proceeded by feelings of weakness ,I have had MRI on cervical spine and it shows 2 bulging discs with bony growths but they tell me it shouldn't be making me feel this way .I also get ectopic beats in my heart and have had this investigated but this has been proven harmless.My doc has given me meds for anxiety as I am very worried about all this! I have tried to get answers to all this but no one can explain it to me. Please can you see if you can help diagnose this, I am a mum of 3 and this is getting in the way of my everyday functioning. MANY THANKS.
Speaker_-_Dr__Clair: This sounds like you have what is called, "cervical disc disease" which is an orthopedic or neurosurgical problem that may require surgery to fix. It is difficult to fully assess this without reviewing the images. This is not carotid artery blockage, but may instead be related to compression of the spinal cord from discs between the vertebral bodies in your neck. I would recommend a visit with an expert in spine disease, such as you would find at our Center for Spine Health here.
has50: My mother is 80 years old and recently lost the feeling of her left side for about 10 to 15 minutes. Her feeling came back but then she went to the doctor and had tests done. She has 60 percent blockage in her carotid artery and about 60 percent in her brain area. The doctor said he would not do any surgery on her at this time. Why? As she had symptoms, do you think she is at risk for a big stroke? Is there anything she can do to reverse the blockage?
Speaker_-_Dr__Clair: It sounds as though your mom had a mini stroke or TIA. This is a strong warning about her potential risk for stroke. If the narrowing is on the side that is relevant for her symptoms (strangely enough that would be the side opposite of the side that she had her symptoms on), then most vascular specialists would recommend or at least further discuss with you the option of carotid stenting or surgery. We would be happy to evaluate your mother at the Cleveland Clinic.
golfer: I have been having drop attacks. I get slurred speech and both my legs and both my arms are uncontrollable. I go down but am still conscious but unable to get up for about 5 minutes. My carotids are clear but I have FMD. The FMS is not severe enough to cause my arteries to become blocked. I have had angiograms, MRI's, MRA's, CT's, CTA's, EEG's, TEE's, UltraSound's. and various other tests. Are there other tests that I could be given that would show if the problem is my heart?
Speaker_-_Dr__Clair: Your symptoms sound as though you have a much more complicated condition than could be discussed during this chat. You require an evaluation with a neurologist or syncope (fainting) specialist to determine the underlying cause of your condition and to see if it may be anyway related to the FMD. That could be done at the Cleveland Clinic or at a large specialty center locally.
Carotid Artery 100% blocked
scared: i have a carotid artery that is 100% blocked the doctors said they cant fix the artery that is 100% blocked is this true?
Speaker_-_Dr__Clair: Carotid arteries with 100% blockage can be fixed but the risk of fixing them is much higher that leaving them alone and there is a very high and real risk that they can block again, and in 1/3 of cases, this can lead to a stroke. for this reason, most surgeons do not treat 100% occlusion. If there are problems with flow to your brain from this blockage, it could be treated with a bypass to reroute the blood flow around the blockage, but again, this would not be done unless there were symptoms related to this.
Carotid Artery Disease Prevention and Progression
kids12: For 41 years I have lived with diabetes mellitus. Routinely for the last 15 years my triglycerides has averaged 67, cholesterol 172, HDL 61, LDL 81, microalbumin <5.0, and blood pressure 120/62. I routinely ride a bicycle 5 miles daily. In 2003 a carotid doppler test showed no, or negligible plaque. In July 2007 a carotid doppler screening results were 59-69% blockage. Without taking high risk medication what can I do to lower the blockage? Thank you.
Speaker_-_Dr__Clair: Unfortunately, there is nothing that currently can make plaque "go away". The best we can hope to do, is prevent progression or perhaps some mild recession. We also would want to make sure the plaque is "stable" or not at risk for developing stroke symptoms. The best ways to do this are to continue your healthy lifestyle, take an aspirin regularly (daily baby aspirin is even adequate), and I would recommend a statin (cholesterol lowering drug to keep you cholesterol within recommended guidelines) which can be prescribed by your primary care doctors. This type of problem - rapid progression of a plaque over a short time - should warrant close surveillance as well with repeat carotid ultrasound within 6 months of the most recent study
WSHS: My Dad died recently at 90 years old. He had dementia the past few years. He knew he had a partially blocked carotid artery for about 15 years. He was of slender build, low cholesterol and low blood pressure until his seventies. He was a smoker for 35 years but quit around the age of fifty. I am built like him and have low blood pressure. My cholesterol is 205. I have never smoked. Does heredity play a major role or was my Dad's blockage probably caused by his many years of smoking?
Speaker_-_Dr__Clair: Heredity clearly plays a role, but what we do also has significant impact as well. The fact that you don't and have never smoked is in your favor. Despite this, the fact that he had carotid disease puts you at more risk for this problem than someone who has no family history of carotid disease. You should have your physician examine your arteries to make sure there is no evidence of disease when you have your regular check-ups. HIs dementia, most likely, may not have been related to his carotid disease as there are numerous other causes that are more common than carotid stenosis
gogirl: My father had carotid surgery about 2 years ago. He recently had symptoms and went to the doctor. He had an ultrasound and in the same artery, it is now 95% blocked. Is that possible? What do you do if it is reblocked?
Speaker_-_Dr__Clair: Recurrent carotid artery narrowing occurs anywhere from 4 to 10 percent of the time. It most often occurs within the first 2 years of surgery. This is a situation that carotid stenting has an advantage with reduced risk for patients than repeat surgery. Again a number of other factors affect the decision to treat this - but it would sound as though if your father was healthy, carotid stenting would offer a reduced risk of stroke. We offer both carotid stenting and surgery and have extensive experience with treating patients with recurrent carotid artery disease.
kjf: I have heard that if you have a blockage in your carotid arteries, intravenous EDTA can take the plaque out and will open the arteries. Is this true?
Speaker_-_Dr__Clair: I think this relates to chelation therapy, which is a method of treating patients for lead poisoning. It has never been proven to be effective for treatment of atherosclerosis in multiple clinical trials. There is however no currently proven method to medically reduce carotid artery narrowing.
gerrygirl: My mother had carotid artery surgery. They said the blockage was calcified. Am I at risk for this? Should I stop taking calcium supplements?
Speaker_-_Dr__Clair: Because of your family history your are at risk for atherosclerosis or cholesterol build-up in the arteries. I know of no proven relationship between taking calcium an calcification of plaque in the arteries.
gogirl: Is there a link between high blood pressure and carotid artery disease?
Speaker_-_Dr__Clair: Simply put - yes. High blood pressure increases the risk of atherosclerosis and the rate at which it progresses. Control of blood pressure is an important way to reduce your risk of developing atherosclerosis everywhere.
beng: I am a healthy 40 yr old male, I have a family history of carotid and heart disease on my fathers side. I started taking Zocor about 3 months ago as my Cholesterol was 232, LDL 169 and my HDL was 50. Will this drug therapy prevent me from getting the vascular disease, with other risks controlled
Speaker_-_Dr__Clair: There is no drug that can assure that you will not develop atherosclerosis especially if you have a very strong history of cardiovascular disease in your family. I would think in your case the goal with your statin therapy would be to get your cholesterol levels within AHA guidelines. While medicine is a great therapy for elevated cholesterol or blood pressure, you as an individual can have a much greater effect than any medication we can prescribe with regular exercise and modest weight loss. Decreases of up to 30 to 40 percent in serum cholesterol and blood pressure have been noted with employment of these two non-medication methods. Adding this to your drug regimen can have a profound impact on your ability to decrease the progression of atherosclerosis.
Speaker_-_Dr__Clair: There is unfortunately no medicare coverage for carotid artery screening. Recommendations as to when an individual should be screened vary. In most instances I would recommend you talk to your doctor as to his or her guidance as to when and whether you need screening.
mikeyk: If you have a blocked carotid artery in the right side of your neck, is there anything you can do to avoid a procedure? Can you watch your diet and exercise? Will the plaque go away?
Speaker_-_Dr__Clair: If the blockage is not severe, then you need only to modify your lifestyle diet and exercise routine. This should include smoking cessation, treatment of high blood pressure and treatment of cholesterol. In addition attention to diabetes and any other medical conditions should be optimized. Doing all of these things can reduce the risk of progression of the disease and therefore reduce your risk of having anything done surgically.
costela: Does the incidence of carotid artery disease increase after age 60?
Speaker_-_Dr__Clair: The simple answer is yes. The incidence continue to increase as we age. Obviously a number of other factors affect the development of this as well. Family history, smoking play the most dramatic role.
greentea: If you have blockage in your legs are you at higher risk for blockage in the other parts of your body. Does atherosclerosis affect you everywhere?
Speaker_-_Dr__Clair: Atherosclerosis is a systemic disease that affects all arteries to a greater or lesser extent. With someone who has atherosclerosis in one area, there is about a four to five times incidence of having disease elsewhere including the carotid arteries. If you are seeing a vascular specialist for your leg problems, they should at least be assessing and discussing with you your other at risk areas.
When do you require a procedure to treat carotid artery disease?
mich: My 82 year old mother has a 75 percent blocked carotid artery. She is very active. She takes blood pressure medication and a baby aspirin. The doctor told her she does not need a procedure. How much blockage do you need to require a procedure? We have vascular surgeons at a number of facilities that could see your mother and evaluate her for this problem
Speaker_-_Dr__Clair: If your mother has any symptoms related to the carotid artery, such as stroke or mini-stroke --also called TIA's- then she should have something done to treat the narrowing. Without symptoms it is not as clear and would be best handled by an evaluation by an vascular surgeon or vascular specialist. Information regarding risks can be very helpful here. Normally we would not recommend therapy unless there were more than 80% blockage, but it depends upon what tests determine, the degree of narrowing, along with an assessment of what kind of risk a person would have with treatment.
costela: When is surgical treatment necessary for carotid artery disease and what surgical options are available?
Speaker_-_Dr__Clair: This is much more complicated than it would appear. Normally presence of symptoms affect the decision to treat a carotid artery narrowing. If someone has symptoms related to carotid artery narrowing, the indication for treatment would be at least 50% narrowing of the carotid artery. Without symptoms, intervention is usually withheld until a more significant narrowing is noted. Ultimately the decision to treat someone for carotid artery narrowing depends on a number of factors with the ultimate goal being to offer the person the lowest risk with medication, surgery or stenting.
Carotid Artery Stent and Carotid Artery Surgery
mich: What is best – carotid artery surgery or a stent?
Speaker_-_Dr__Clair: Great question. This really depends on the patient's risk for surgery vs. the patient's risk for a stent. In fact in some situations, medications may be a better approach than either of these two options. Normally what we try to offer patients, is an approach that is best tailored to their risk profile. We know there are situations where stenting is better such as recurrent carotid stenosis or if a patient had prior radiation therapy. But there are instances where surgery is better as well such as someone who has abnormal or aberrant anatomy making stenting more difficult.
Speaker_-_Dr__Clair: The key is to identify the risk factors for each and offer the person the better risk option.For low risk individuals who are candidate for either surgery or stenting we are currently participating in a national trial funded by the NIH called the CREST trial, which is a randomized trial designed to evaluate whether stenting or surgery is better in this patient population.
rg52: Do they use drug eluting stents in the carotid arteries – I heard those were bad and I may need a stent
The risk of recurrence of narrowing with stents appears to be low as it is with surgery and the need for medication in a stent therefore is not as great as it is for coronary artery stents.
marie: My husband has right artery stenosis and left carotid artery stenosis. Can they be treated at the same time? Is angioplasty better for this or should he have surgery? What is the expected outcome?
Speaker_-_Dr__Clair: There are many issues that would affect the choice to treat or not treat carotid artery narrowing. In most instances the lesions are treated separately and at separate times. The choice of stent vs. surgery vs. medication depends on a thorough review of his risk factors.
Speaker_-_Dr__Clair: When treating patients with carotid disease with surgery risk of stroke varies according to whether the patient has symptoms or not. Without symptoms, most patients can expect a stroke risk of less than 1 percent with an experienced surgeon. Ours at Cleveland Clinic is 0.7 percent. For symptomatic patients that risk is slightly higher.
Speaker_-_Dr__Clair: For carotid stents, in a patient who has no symptoms, the risk of stroke should be somewhere between 1 - 2 percent. While this risk is slightly higher than with surgery, there is essentially no risk to the nerves to the neck region which can sometimes be affected by surgery. On the whole, it appears that these two methods of treatment are fairly similar in their risk profile for low risk patients. This is why the NIH has funded a 2500 patient trial that I mentioned before called the CREST trial to assess which of these two types of treatments is better. We are currently actively seeking patients for this trial and would be happy to discuss it further for those who are interested.
Carotid Artery Diagnostic Testing
mikeyk: What is a carotid angiogram? My father needs one. If they see blockage can it be fixed during the procedure?
Speaker_-_Dr__Clair: Most patients with carotid artery narrowing do not need carotid artery angiography and performance of this procedure increases risk. Normally it is only done in situations where noninvasive testing cannot provide adequate information. In our experience this is less than 10 percent of patients with carotid artery disease. Normally carotid ultrasound is a screening test that is used to screen for carotid artery disease and this can be confirmed and enhanced by CT or MR angiography. These pose essentially no risk and offer excellent information about the arteries and their degree of narrowing.
Other Types of Vascular Surgery
afg123: How are spider veins removed?
Speaker_-_Dr__Clair: There are a few questions about spider veins which are unrelated to carotid disease, but are a vascular issue. Spider veins are a dilatation of small veins in the legs that are common in women, especially after or during pregnancy. These are caused by increased venous pressure which causes the vessels to be stretched leading to their abnormal appearance. They can be treated by several different methods and the most common are either laser or sclerotherapy - an injection of an irritant which causes the veins to recede.
worried: I have been diagnosed with a carotid tumor. Is that deadly? Can it be surgically treated?
Speaker_-_Dr__Clair: It sounds as though this is a carotid body tumor which are not normally deadly but can be locally aggressive and for that reason most would recommend removal of this tumor. The size of the tumor affects the risk of removal with smaller tumors having the lower risk
Speaker_-_Dr__Clair: When choosing a physician to treat, make sure they have a multidisciplinary team including both a head and neck surgeon and a vascular surgeon, such as the Cleveland Clinic or another large center.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Clair is over. Dr. Clair thank you again for taking the time to answer our questions today.
Speaker_-_Dr__Clair: Thank you for having me
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