Carotid Artery Disease

Podcast Transcript

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Sean Lyden, MD:
Hello everybody, I want to welcome everybody today. My name is Sean Lyden. I'm the chair of vascular surgery at the Cleveland Clinic, and I'd like to introduce my other two physicians we'll be working with today. One is Dr. Scott Cameron, who is the chief of the Department of Vascular Medicine and Dr. Christopher Bajzer, who is one of our intervention cardiologists. And we're going to talk a little bit today about carotid artery disease, where it sits in 2021 and sort of the things we should know. So maybe we'll start off with Dr. Cameron, and maybe you could tell us a little about for the patient out there, what they should know about carotid disease? Who gets it? Who should be checked for it, and how should it be sort of managed?

Scott Cameron, MD, PhD:
Yeah, that's a great question Dr. Lyden. what I find is a lot of carotid diseases find incidentally patients may have some unusual neurological symptoms such as blurry vision, double vision, and then they'll have some kind of imaging study done of the neck. And then we find out that there's some narrowing of the carotid artery. And then, from my decision making, it's a case of, is this something that we treat medically? As you know, many of them we do treat medically, or is this something that needs an intervention?

Scott Cameron, MD, PhD:
Now on the other hand, sometimes when I'm examining a patient, if I am treating a patient with coronary artery disease, for example, as we know one third of those patients also have peripheral artery disease. Sometimes that manifests in the carotid. So if I'm listening to them, and I hear a bruit, which is basically narrowing in a blood vessel, I can't tell how narrow that is, but then ultrasound will settle that out for me. And so by using the ultrasound, you can then determine, is this something that we would continue to manage medically? Or is this something that even though that patient doesn't have symptoms, should we consider referring them for a surgical procedure or stenting of the carotid artery?

Sean Lyden, MD:
And Chris, you as a cardiologist take care of people with heart disease all the time. I think one of the things that I struggle with as a vascular surgeon is when we see people, most of these problems are managed medically, and trying to explain to the patient that all these things that control their medical risk factors are so important. What are the kinds of things we talk to the patients about, about things that they need to control, watch out for that overall is going to help reduce their risk of carotid problems, but really hurt their overall cerebral vascular care and their heart, and other places in their body?

Christopher Bajzer, MD:
That's an excellent question. And I always sit down with my patients and I talk about things that I consider to be not modifiable, which would be things like genetics. You cannot change your family and what your genes are that you inherited from your ancestors. And usually males will have this disease more frequently than females, but it is a disease that will affect females as well. But I spend a lot of my time talking about the modifiable risk factors, which would include and most importantly, the use of tobacco and tobacco cessation being a prime importance. And then we also will talk about cholesterol, which can be either dietary. So we talk about limiting fats and cholesterol in the diet, and/or perhaps the use of medications, such as statins to be able to control the cholesterol that of course will contribute to the development and progression of this disease.

Christopher Bajzer, MD:
And then we also talk about blood pressure control, and it's important to make sure that blood pressure is controlled according to what the latest guidelines would say, which for most people with any sort of vascular disease, you're looking for a top number or a systolic blood pressure, less than 150, or a diastolic blood pressure, a bottom number less than 80. And of course if somebody has diabetes, it's important that they have very close follow-up with either a primary care physician or perhaps an endocrinologist specializing in diabetes care to be able to make sure that they're managing that appropriately through the combination of diet and exercise and medication.

Sean Lyden, MD:
I think one of the things we've seen rise in the last 10 or 15 years is use of vaping where people have replaced what we think is traditional tobacco products was still the inhaled vapes that people see as not smoking. I guess Dr. Cameron what word of advice would you give to the patients out there in terms of what their cardiovascular risk, or their stroke risk, or carotid risk when they try and replace cigarettes or other forms of tobacco with the vaping mechanisms?

Scott Cameron, MD, PhD:
Yeah. So that's a really interesting question. So one of the things that we recognized almost immediately with vaping is that although you're removing some of the tobacco products, vaping is in itself inflammatory. And so as we know arterial disease in any part of the body, if you have a narrow blood vessel, inflammation is a very big part of that. And it turns out that vaping inflames the inner lining of the blood vessels, the endothelium, and it also activates platelets. So the circulating cells that are involved in blood clotting. A number of studies now have shown that some of these protective mediators from that inner layer of the carotid artery, nitric oxide for example, that's decreased by vaping. And so if you take someone that as Dr. Bajzer said, has a substrate already of high cholesterol, maybe high blood pressure, they've got risk factors, if they vape on top of that, you may have somebody who already has some narrowing of the carotid artery, but then they could just cause a little piece of that plaque to break off. And that might manifest as a neurological symptom or a transient visual disturbance, depending on if a little piece of that plaque goes to the brain, and also effects one of the nerves in the brain, or maybe even goes to the retina at the back of the eye and effects a small blood vessel there. So vaping is an important one to talk about, and I think sometimes we forget to do that.

Sean Lyden, MD:
And so the patients always say, well, what am I at risk of? And we say stroke, and maybe Dr. Bajzer you could talk about sort of some of the symptoms that patients might self-identify at stroke that might illicit them to seek emergency care and ER. What are the stroke symptoms? And then what we really call a mini stroke, and then how we divide up treating patients, whether they're symptomatic or asymptomatic of how tight of a narrowing that we get worried about.

Christopher Bajzer, MD:
That's all very excellent questions. And I often will have conversations with my patients in the office if we know that they have carotid disease, it is very important to know when do you actually go to an emergency room? If you have a loss of vision, similar to a window shade being pulled over a single eye, that would be a sign of potentially some clot or a piece of cholesterol being moved from the carotid artery and up into the brain. Specifically, actually into the back of the eye, and then the vision in the eye is shut off, much like you would turn off a camera. And then if the body is able to clear that, that vision is then restored, and that in and of itself is a red flag and should be evaluated in very quickly in the emergency room, because it may be a harbinger of a more significant event to come.

Christopher Bajzer, MD:
The more significant event would be obviously if some of that material would actually end up actually in the brain, and then you would lose control of one side of the body or another, whether it be an arm or a leg, but you would lose control, or the voluntary movement of that portion of the body. That would be again, another red flag that would warrant evaluation in emergency room.

Christopher Bajzer, MD:
The third thing would be some asymmetry of the face, which mostly would be noticed by a family member who would look at the patient and say, well, something's not quite right, and give me a smile, and they would find an asymmetry of the smile. Or if a person is not able to articulate speech in a normal fashion, or it's a garbled speech, or they don't comprehend someone speaking to them. Those would be all red flags that should be evaluated in an emergency room, because really time is of the essence. Much like a heart attack, this is actually a brain attack. And the sooner you can get to an emergency room, the better off that you have of a recovery.

Sean Lyden, MD:
And so along those lines, Dr. Cameron, what degree of narrowing, would we benefit somebody by fixing those blockages if they've had stroke symptoms, as opposed to someone who's yet to have stroke symptoms? And what do we look at as doctors to say, when is it time to sit there and say, should we intervene? And then we can get to how we might intervene.

Scott Cameron, MD, PhD:
Now that's a really good question. One of the things we're really blessed with, as we know, the vascular lab here sees about 70,000 studies a year, and so our sonographers are very, very good at carefully assessing just how narrow the carotid artery is. So if somebody has symptoms and the carotid arteries within the moderate range of narrowing, the guidelines do tell us that that in fact is a patient who would benefit from revascularization. That means that either a surgical procedure or stenting, to make sure that the blood flow is restored, and the sooner you do that, the better. This is something if you've had symptoms and a physician has said that there's only moderate narrowing, not severe narrowing, that sometimes patients that do benefit from interventions, we have good data on that, as well as medical management.

Scott Cameron, MD, PhD:
But clearly a patient that has severe narrowing of the carotid artery, so by severe there's different criteria we look at when we look at how fast blood moves through it. But typically if the blood vessel is narrowed by about 70% or more, most societies would say that's severe narrowing. So then a patient who has that, even if they don't have symptoms, it's incredibly important because we know from the scientific data, you actually need to treat a single digit of patients less than 10 to prevent one stroke. And that's why I would very aggressive at referring our patients to surgeons and interventional cardiologists when appropriate to fix that.

Sean Lyden, MD:
So when I first started training, surgery was really the only option to fix a carotid where you would basically stop blood flow, scrape out the blockages, restore the artery to its clean normal status, and then restore flow. And actually when I first got here 20 years ago, Dr. Bajzer spent a lot of time teaching me a lot of the endovascular techniques to treat the same artery, but doing it through a puncture in the groin, or now sometimes a puncture in the neck where we put a stent in. Very similar to we do to the heart arteries. And there's actually now good data showing that both for high-risk and low-risk patients at five years, they're really both similar outcomes. And so you can treat people very well.

Sean Lyden, MD:
Chris, how do you decide, as an interventionalist, of who should have an intervention or who to have surgery? And then maybe we'll ask Dr. Cameron and I'll comment, because we do know there's data showing they both work very well in a lot of those studies, we were part of it, at the Cleveland Clinic, or even help drive to show the data's equivalent, but yet a lot of other factors sort of imply of what we can offer patients.

Christopher Bajzer, MD:
Those are excellent questions. And I think in my practice, if a patient is extremely old, that is 82 years of age or older, or if they have failed kidneys, end stage renal disease, we know from a lot of the studies, both here and around the world, that those people do not do well with carotid stent procedures. I personally say that if a person has had coronary stents, or stents elsewhere in the body, say in the legs, and they've been prone to have re-narrowing or restenosis of those stents, those patients I will tend to steer towards surgery as well, because the chance of having potentially restenosis of a stent in the carotid would be potentially higher. Currently, we know that it's about 1%, which is a lot better than say even the best coronary stents, but if people have shown that to have aggressive disease, I think that those are the patients that probably should go to see a surgeon and have that repaired.

Sean Lyden, MD:
I think the other thing that we have a lot of different ways to protect a brain when we do carotid stenting, we have filters that are sort of like fishing nets. So you put distal while you're working, or we can have devices that stop flow or reverse low approximately. And there's times where you're built on the inside anatomically that may affect whether it's able to do that or not. So if there's a lot of disease in the chest, or a lot of bendiness in a chest trend and negotiate from the groin up there can be more difficult and more prone to risk. And so sometimes we might be able to do it through surgery or just through a puncture through the neck. And I think there's other times when the artery has a lot of bendiness or torturous above there, we can pick different strategies to do it. But I think the really key thing is that in skilled hands, they both really have very similar outcomes.

Sean Lyden, MD:
And so sometimes, I choose surgery, sometimes I choose stenting, and I think really, there is some advantages and disadvantages to each. I think the sicker someone's heart is we do know that stenting probably carries a little less stress on the heart, but maybe in some studies a little bit higher stroke risk, but surgery carries a little higher heart attack risk and a little bit lower stroke risk. So you have to balance all those issues. And so when you see somebody in the office, Dr. Cameron, how do you decide to say, well, what should we do or see? And I think because sometimes people can only own one option, whether it's surgery or stenting, or sometimes do both. And so what are the kinds of things you try and talk to your patients about when you feel it's appropriate that they'd have their disease addressed?

Christopher Bajzer, MD:
So what I typically do with patients is I'll kind of meet them where they are. Sometimes the patient may have a fear of a surgical procedure or stenting. They don't want to undergo that. I try and make it clear what the guidelines show and what the data shows. So if somebody has moderate narrowing in the carotid artery, and they have symptoms or if they have severe narrowing, no symptoms. I think that the data is very clear. So I firstly discuss that with the patient, but then the second thing is just has already to come up, I consider other things that are going on with a patient. For example, I had a patient with coronary artery disease that we had performed a peripheral intervention on, and just examining him, he had a carotid bruit. And so we did the ultrasound and he actually had complete occlusion or blockage of one artery, but then he has an 80%, 85% narrowing here.

Christopher Bajzer, MD:
He had multiple medical issues. He had already sustained a stroke in the past. This is a very, very high risk individual, but he's basically living off of a thread, and one of the things we're really fortunate in Cleveland Clinic, we're so used to seeing patients like that. And so he was actually the first patient at my prior institution that went through the procedure just as you described. And I remember explaining it to him this way, well, the stroke risk. I know that that's something you'll be fearful of if you've had one, but this is a special procedure where they can actually place the stent from the outside, and while they're doing that, they have a device placed so that they're stopping blood flow from going up to that part of the brain just temporarily. And they're basically putting it back in the body and they're preventing if a little piece of plaque breaks off, they're making sure that that won't go to the brain. And he did fantastically with that procedure. And at the end, he went in fearful, but ultimately thanked us for recommending it.

Sean Lyden, MD:
And I think those are all really good points. And I guess, we talked about primary prevention, Chris, as you talked about modifiable factors. After we do surgery or do interventional therapy, can patients just stop all those therapies with their cholesterol and their blood pressure. And I think that's something that people sometimes think, well, we fixed it, I'm good. Can I just not having else done? And I think that's one things we also have to really encourage our patients is that this is a lifelong process. So what kind of discussions do you have with them afterwards in terms of once they're done, so that we don't end up working more on other parts of their bodies?

Christopher Bajzer, MD:
Well, that's absolutely correct. I mean, this is a whole body process. So while it may manifest in one location of the body or another, whether it be heart or the carotid artery, or maybe a leg artery, it is a whole body process. And so while one part of the body may need to repair with either surgery or stenting, it is a whole body process. And it is, as I tell patients, I wish we had Harry Potter's magic wand. They give it a swish and a flick, and we could make the disease disappear, but we don't have that. But nonetheless, we do have all of this treatment and it is very successful, but it requires diligence and continued monitoring throughout a person's life from the time that we detect disease and that point forward. It is a lifelong process.

Sean Lyden, MD:
So Dr. Cameron, I guess, what are the other things you'd want to get across to patients that's is sort of high-level that they'd remember in terms of what we've discussed here today? And then, if they had more questions, where might they find in the Cleveland Clinic resources, a place to sort of to get more information on carotid disease and how we treat it here in Cleveland?

Scott Cameron, MD, PhD:
I think the biggest thing to emphasize is that we truly are multidisciplinary. And so a patient who may have carotid disease can benefit from the consultation collaboration of vascular medicine physicians that maybe don't do procedures, cardiologists, interventional cardiologists, as well as surgeons. And we make those decisions together for the betterment of the patient. The website that we have has some really fairly up to date actually, and quite comprehensive information on what carotid disease is and risk factors. And one of the things we sometimes find when patients come here is that other medical things that may have led to carotid disease, if not tobacco, such as unusual types of cholesterol, the patients might carry. We know that there's a special type of cholesterol called lipoprotein(a) that's very much associated with narrowing of the carotid artery. I see many of those patients. We can detect that. We can get the result within a day, and we can put them on the appropriate medications.

Scott Cameron, MD, PhD:
And not only that, patients also have the benefit of access to the most up-to-date medications, devices, and sometimes clinical trials. When we've got a new medication that has proven to be very promising in preliminary studies. Patients sometimes like to enroll in those studies and get that most up to date treatment. And typically we will advertise those on our website also.

Sean Lyden, MD:
So one question we get asked a lot is, what do I do, or what are my options when one of my carotid arteries is completely blocked or 100% blocked? And so maybe I can ask both Dr. Bajzer first, and Dr. Cameron to comment a little bit about what that means for the patient, what their options are, and then what they should have done for evaluation and follow-up and where they stand. What are their risks? Dr. Bajzer.

Christopher Bajzer, MD:
If a person does have a completely closed artery, but has not suffered a stroke, that to me tells me that that person has had an alternative way of getting blood flow to the brain. And it's an amazing thing. The brain is terribly important as an organ for the human being. We don't have one, two, three, but we have four arteries that go up and feed the brain. And that in the base of the brain, there is interconnections between these arteries that we all have at birth. And if we're lucky we get to have, as we get to be older, and oftentimes one can have a complete occlusion and not suffer a stroke. This does make disease in the remaining open arteries that much more important. So to the point of what to do, actually, we usually will not operate or will not put a stent in the closed artery, but we will keep careful surveillance on the other arteries that are now of course, more importantly, feeding the brain, and then really focus aggressive attention on all of those medical risk factors that we know will contribute to the progression of disease in those other arteries.

Sean Lyden, MD:
So, Dr. Cameron, what is the risk when an artery closes of having a stroke? And then if they've not had a stroke, what's the risk of a future stroke on that same side going forward? And so I think that's the big question and the fear people have, is it's blocked, am I still going to have a stroke on that side? And so I think it's before it closes, what's the risk, and after it closes, what's the risk going on? And what kind of information can we give to those patients?

Scott Cameron, MD, PhD:
So two important things I always like to bring up. I have occasionally, I will say seen a patient who has been told that they have a complete blockage in a carotid artery. It just depends on the type of imaging that they've had done. I have actually seen a few patients where there is flow in that artery, and that's a very important distinction to make. I'm not saying that every patient that has been diagnosed with a blocked artery should hope that they can find an imaging technique to say it's open. But I think it is important to clarify whether it is truly completely blocked, because as you well know, if there's residual flow even 10%, 15%, some of those patients can get benefit from certain procedures.

Scott Cameron, MD, PhD:
I usually tell patients if you've not had a stroke, and you find yourself to be completely blocked on one side, the most important thing that we can do is be extremely aggressive about medications and risk factors to prevent you from having a blockage in another artery or a piece of plaque breaking off. Because if you've had one artery that's narrowed a patient's body's telling me that it has the ability to narrow arteries. And so we must be extremely aggressive, even if a patient has never had symptoms.

Scott Cameron, MD, PhD:
Now for a patient who has a complete blockage on one side, I would tend to agree, a common question that we have is should we find somebody that will open that? And the data's quite clear actually. With a complete blockage, the brain has got this wonderful capacity to divert blood flow so that the amount of blood flow that's seen throughout is actually no different. And it can do that by just adjusting within the brain the amount of blood flow going up the other artery. And so just being aggressive with risk factors and seeing if there's residual disease. If we do an ultrasound, for example, if I see some soft plaque there, we know that patients with soft plaque, those are the patients that are higher risk of that soft plaque breaking off. And so I might decide to give a different combination of medications, a different combination of platelet blockers, or blood thinners if you will, depending on what I see in the artery that is not narrowed, even though the other one might be completely blocked. So that's a good question.

Sean Lyden, MD:
I think those are key points. I mean, for the patients before the artery blocks up and closes, when it closes abruptly, there at least one in four patients can have a very disabling stroke. Once it's totally blocked, and they haven't had a stroke, as everybody's pointed out, there's really good flow from the other parts of the brain. And so it's really about getting rid of those risk factors that are modifiable, and getting them as best as possible to preserve the other arteries. And so opening up a blocked artery after it's confirmed truly to be blocked is really not beneficial, and we know that has even a higher stroke rate than leaving it alone.

Sean Lyden, MD:
With that, I really want to thank both Dr. Bajzer, Dr. Cameron, and the people that have either watched or listened in today with our little update on carotid artery disease. If you have more questions the Cleveland Clinic website will have more on the three of us, as well as the Heart and Vascular Institute, and how we work very well together to make sure that we treat the entire person.

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