Carotid Artery Stenting

What is carotid artery stenting?

Carotid artery stenting is a procedure to prevent a stroke. A healthcare provider can perform this procedure if a carotid ultrasound, CT scan or MRI shows you have a blockage in your carotid artery. Your carotid arteries are blood vessels that supply blood to your brain, face and neck. Sometimes, a fatty material (plaque) builds up in your arteries and causes a blockage.

A healthcare provider can put in a stent (a small, metal mesh tube) to open the blockage. Putting a stent in your carotid artery keeps it open to allow better blood flow to your brain. This lowers your risk of a stroke.

The stent stays in place permanently. It acts as a scaffold to support the artery and keep it open. After several weeks, the carotid artery heals around the stent.

Depending on what part of your carotid artery has the blockage, a provider will use a specially designed stent that is specifically approved for this purpose. The place where your carotid artery branches to supply your face and brain is the most common place for a blockage to happen.

A specially trained provider performs carotid artery stenting. This can be an interventional cardiologist, vascular surgeon, endovascular neurosurgeon, interventional neuroradiologist or neurologist. They can access your carotid artery by way of an artery in your leg or arm or through your neck (where your carotid artery is). Your provider can tell you which method is best for you.

What does it treat?

A carotid artery stenting procedure treats carotid artery stenosis (narrowing). The U.S. Food and Drug Administration (FDA) approved carotid artery stents beginning in 2004. People who get this procedure usually have:

• Stroke or ministroke symptoms from a carotid artery blockage of more than 50%
• A carotid artery blockage of 70% or more without symptoms

How should I prepare for carotid artery stenting?

You may need to take aspirin and a second antiplatelet medicine (like clopidogrel, ticagrelor or prasugrel) for three to five days before your carotid artery stenting procedure and continue after the procedure. Failure to take these medicines will require a delay in performing your procedure. Your provider will give you specific instructions about what you can and can’t eat or drink before the procedure, too.

What happens during carotid artery stenting?

Your healthcare provider may perform one of two types of carotid artery stenting:

• Transfemoral or transradial percutaneous carotid artery stenting
• Transcarotid artery revascularization (TCAR)

The type determines how they’ll access your carotid artery. The procedures are somewhat similar except for the access point and the way they deal with plaque particles. Your provider will choose the best option for you.

Access points for each procedure are:

• Transfemoral carotid artery stenting: Through your femoral artery in your leg
• Transradial percutaneous carotid artery stenting: Through your brachial or radial artery in your arm
• TCAR or transcarotid arterial revascularization: Through your carotid artery just above your collarbone

During the procedure, you’ll receive medication like heparin or bivalirudin to reduce the risk of blood clots. You’ll need to keep the site of entry (leg or arm) straight and still for two to six hours after the procedure.

How long does it take?

A carotid artery stenting procedure usually takes about one to two hours. However, the preparation and recovery time add several hours. You can expect to stay at the hospital all day for the procedure and will stay overnight.

What happens after carotid artery stenting?

After a provider places the carotid artery stent, they’ll:

1. Perform an angiogram to confirm that the stent expanded completely and that it corrected the narrowing or blockage.
2. Remove the sheath, catheter and any other tools. The stent will stay in permanently.
3. Give you medication to reduce discomfort.
4. Check in on you and give you tests to see how well the procedure worked.
5. Discuss the results of the carotid artery procedure with you and your family.
6. Give you instructions about your medications, meals and activity.
7. Prescribe aspirin and a second antiplatelet medicine (clopidogrel, ticagrelor, or prasugrel) to take after the procedure. These medications help prevent blood clots from forming at the site of the carotid artery stent placement.

Follow your healthcare provider’s instructions about how and when to take these medications. Don’t stop taking them without first talking to your provider. They’ll determine how long you’ll need to take these medications, but it will be at least one month. But in many cases, it’s at least six months.

What are the benefits of carotid artery stenting?

People who have carotid artery stenting instead of a carotid endarterectomy have these benefits:

• A less invasive approach
• Smaller incisions or no incision
• Less risk of nerve damage in the neck
• Less pain after their procedure

How successful is this procedure?

For most people, carotid artery stents increase blood flow to their brains and decrease their risk of a stroke.

Researchers have compared the results of the carotid stenting procedure with that of the carotid endarterectomy surgery. Studies have found that there were no significant differences in major risks of the two treatments through 10 years.

However, people who get a stent in their carotid artery may be more likely to have a minor stroke. But they also don’t have the risks of nerve damage.

Both treatments have similar rates of restenosis (an artery getting narrow again). This can happen in the first two years due to scar tissue or later from the process of atherosclerosis or hardening of the arteries. Both treatments have a likelihood of being a lifetime repair in over 95% of cases.

What you can do to improve your prognosis

Although the carotid stenting procedure opens up a blocked carotid artery, it doesn’t cure carotid artery disease. You’ll still need to focus on reducing your risk factors and making certain lifestyle changes to prevent atherosclerosis from developing or getting worse.

For the best results, follow these recommendations:

• Avoid all tobacco products, including vaping.
• Take medications as prescribed.
• Stay at a weight that’s healthy for you.
• Get regular physical activity.
• Follow a heart-healthy meal plan.
• Manage blood pressure (under 130), cholesterol (LDL under 70) and diabetes (HgBA1c below 7).
• Go to follow-up visits as your provider recommends.
• Have follow-up imaging of your repair and the opposite carotid artery with ultrasounds.

What are the risks or complications of carotid artery stenting?

Some of the possible carotid artery stenting risks include:

• Hypotension
• Hypertension
• Bradycardia
• Bleeding at the catheter insertion site
• Bleeding at your neck incision site for TCAR
• Damage to your leg artery, arm artery or carotid artery
• Blood clots
• Stroke
• Brain bleeding
• Death

There may be other possible carotid artery stenting complications. When you meet with your healthcare provider, ask questions to make sure you understand the potential risks and benefits of the procedure. Certain risk factors may make you ineligible for carotid artery stenting.

Carotid artery stenting risks vary depending on:

• The severity of your disease.
• The location of the blockage.
• Whether you’ve had a previous stroke.
• The presence of other medical conditions.

What is the recovery time?

You’ll need to take it easy for a few days after the carotid artery stenting procedure.

Follow these guidelines:

• No heavy lifting (more than 20 pounds) for one week after the procedure.
• No soaking (meaning no sitting in a bath or going swimming) the area of skin puncture for seven days. Showering is OK.
• Use a slower pace when climbing stairs.
• Gradually increase your activities until you reach your normal activity level by the end of the week.

If you have bruising in your groin, arm or neck area, it should go away in a week or less.

When should I call my healthcare provider?

It’s important to call 911 or emergency services if you have stroke symptoms similar to what you experienced before your carotid artery stenting procedure. This includes facial asymmetry, any speech issues (like an inability to talk), or an inability to move or feel parts of your body.

If you have any bleeding or drainage from the puncture site, call your provider as soon as possible.

Scar tissue at the treatment site can cause another blockage, or restenosis. This re-narrowing in the treated carotid artery is more likely to occur in the first 24 months after treatment. Providers check for this with a carotid ultrasound. This is why keeping your follow-up appointments is important. Various studies estimate the rate of restenosis at 11% to 40%. However, significant narrowing requiring retreatment occurs in less than 5% of cases.