What is carotid artery disease?
Like the blood vessels of the heart (coronary arteries), the carotid arteries also develop atherosclerosis, the build-up of fat and cholesterol deposits, called plaque, on the inside of the arteries. Over time, the build-up narrows the artery, decreases blood flow to the brain and can lead to a stroke. Read more about carotid artery disease.
What is carotid angiography?
Carotid Artery Anatomy with Angiography
Carotid angiography, also called carotid angio or an arteriogram, is an invasive X-ray imaging procedure used to detect the presence of narrowing or blockage (atherosclerosis) in the carotid arteries and determine your risk for future stroke.
Carotid angiography may be performed when carotid artery disease is suspected, based on the results of other tests, such as a carotid duplex ultrasound, computed tomography angiogram (CTA) or magnetic resonance angiogram (MRA).
What is carotid angioplasty and stenting?
Carotid angioplasty is a non-surgical procedure performed after the diagnostic angiogram. The carotid angioplasty procedure can be performed the same day as the diagnostic angiogram or days or weeks after the angiogram.
During angioplasty, a balloon catheter is guided to the area of the blockage or narrowing. When the balloon is inflated, the fatty plaque or blockage is compressed against the artery walls to improve blood flow.
During the angioplasty procedure, a carotid stent (a small, metal mesh tube) is placed inside the carotid artery at the site of the blockage and provides support to keep the artery open.
For patients who meet certain eligibility criteria, carotid stenting offers a less invasive approach than carotid endarterectomy, the traditional surgical treatment for carotid artery blockages. Carotid stenting can be performed while the patient is awake, reducing recovery time.
What happens during the carotid angiography procedure?
A medication such as heparin may be given during the procedure to reduce the risk of blood clots. You also may need to take aspirin and/or Plavix (clopidogrel bisulfate) for three to five days before the procedure and for four to six weeks after the procedure. Your doctor or nurse will give you specific instructions about what you can and cannot eat or drink prior to the procedure.
First, the doctor anesthetizes or numbs the area where the introducer sheath will be inserted. The sheath is a thin, hollow tube that is inserted into a blood vessel in the leg (femoral approach) or arm (brachial approach).
A long, narrow tube called a catheter is inserted through the sheath, and is guided through the aorta to the carotid artery with the aid of a special X-ray machine.
Some patients may have a second sheath placed in the leg or arm vein where a temporary pacemaker wire is placed in the heart to regulate the heart rhythm during the procedure.
Contrast material is injected through the catheter and X-ray movies are created as the contrast material moves through the carotid arteries (vessels that provide circulation to your brain). The digital photographs of the contrast material are used to identify the site of the narrowing or blockage.
If the diagnostic tests show severe narrowing or a blockage in the carotid artery, the carotid angioplasty and stenting procedure may be performed to open the artery, or surgery may be recommended.
What happens during the carotid angioplasty and stenting procedure?
A specially designed guide wire with a filter is placed beyond the site of the narrowing or blockage in the carotid artery. Once the filter is in place, a small balloon catheter is guided to the area of the blockage. When the balloon is inflated, the fatty plaque or blockage is compressed against the artery walls and the diameter of the blood vessel is widened (dilated) to increase blood flow. The balloon is removed and the stent is placed inside the artery to widen the opening and support the artery wall.
Endotex Carotid Stent
SMART Nitinol Stent
Guidant ACCULINK Carotid Stent System
After the stent is placed, an angiogram is performed to confirm that the stent has completely expanded and the narrowing or blockage has been corrected. Often, a second balloon catheter is inflated to ensure the stent is maximally opened. The stent stays in place permanently and acts as a scaffold to support the artery and keep it open. After several weeks, the artery heals around the stent.
In clinical trials at Cleveland Clinic, several types of carotid stents have been used along with a device called the embolic protection device (EPD). The EPD looks like an umbrella or wind sock and contains a basket to catch plaque particles dislodged during the stenting procedure. Catching these particles prevents them from traveling in the blood to the brain and reduces the risk of a blood clot or stroke.
How long has the carotid stenting procedure been performed?
The stenting procedure has been performed in clinical trials at Cleveland Clinic since the procedure was introduced in 1994 as an investigational treatment for carotid artery disease.
In 2004, the carotid stenting procedure was approved by the FDA as a treatment option for select patients who have carotid artery stenosis and meet certain criteria. The procedure is approved for patients who are experiencing symptoms, have a carotid artery that is blocked 70 percent or more, and for whom surgery would be highly risky.
Research is still ongoing to compare the results of the carotid stenting procedure with that of the carotid endarterectomy surgery. Most recently, a large randomized trial called the CREST trial compared the two treatment options and found that there were no significant differences in major risks of the two treatments.
Reference: Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, Mackey A, Hill MD, Leimgruber PP, Sheffet AJ, Howard VJ, Moore WS, Voeks JH, Hopkins LN, Cutlip DE, Cohen DJ, Popma JJ, Ferguson RD, Cohen SN, Blackshear JL, Silver FL, Mohr JP, Lal BK, Meschia JF; CREST Investigators. Stenting versus endarterectomy for treatment of carotid-artery stenosis. New England Journal of Medicine 2010 Jul1;363(1):11-23.
Common Questions About the Carotid Stenting Procedure
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