Let’s talk about medical management of carotid stenosis.
Risk factors for carotid artery stenosis are advanced age, hypertension, diabetes mellitus, high cholesterol levels, obesity, lack of exercise, smoking, and family history of strokes. Most of these factors can be managed by medications and lifestyle changes that include active exercise for 30 minutes or so on a daily basis. The Mediterranean diet, which is particularly rich in omega 6 fatty acid and includes nuts, fatty fish like salmon, and olives, can lower the LDL (bad cholesterol) and raise the HDL (good cholesterol).
Medications and bariatric surgery are available to lose weight. Several medications (Chantix, Wellbutrin) and nicotine patches can help with smoking cessation and also address underlying depression at the same time.
Control of diabetes and high blood pressure is of paramount importance so that the HbA1c is less than 7. This can be done with a combination of diet, regular consultation with a nutritionist or dietitian, and daily exercise. Simple measures like avoiding carbohydrates after 5 p.m., walking for 10 minutes after meals, avoiding sugary drinks like soda, sweetened tea, and juices and switching to healthier carbohydrate alternatives like brown rice, whole-grain pasta, brown bread or multigrain bread can help control sugar levels.
Several classes of medications are available to control the blood pressure and it is advised to check your blood pressure at home at least three times a week. Cholesterol can be managed with a wide variety of medications. For patients who do not respond to the regular medications, a new (but more expensive) alternative, Repatha, is available to control cholesterol.
Even if you are resolved to surgery, control of the risk factors is paramount to controlling the disease. Without adequately controlling the risk factors, the carotid stenosis or blockage can come right back.
There is very little evidence to resolve to operative management of the carotid artery if the blockage is less than 80%. The benefit of operative management of the carotid artery is seen much less frequently in women, especially if they are smokers, and in patients who have kidney disease. This has been proved multiple times in many research trials. Currently we are waiting for the results of a large research trial (CREST 2), which will change guidelines of treatment in the near future. If the blockage is more than 80%, then cleaning of the arteries is advised. This can be done in several ways.
- Carotid endarterectomy and patch angioplasty: This operation has been around for the past 80 years or so. A cut is made in the artery in the neck, the plaque is cleaned out, and the hole is repaired by putting a patch. Typically, patients go home the next day.
- Transfemoral carotid stenting: This operation has largely been abandoned in favor of the newer transcarotid artery revascularization and stenting (TCAR) due to high rates of stroke in large randomized controlled research trials. At this time, this procedure is only done if the patient’s anatomy is unfavorable for performing TCAR. In this procedure, patients do not need general anesthetic and a stent is placed in the carotid arteries in the neck by accessing the femoral artery in your groin.
- Transcarotid artery revascularization and stenting: In this procedure, which has largely replaced transfemoral carotid artery stenting, a small cut is made above the collarbone and a stent is placed in the internal carotid artery by accessing the common carotid artery at that point. This has been deemed almost as safe as the carotid endarterectomy and patch angioplasty. Note that in the stenting procedure, the plaque is not removed from the body but part is plastered against the inside of the blood vessel by the stent.
BIO: Dr. Aparajita is a fellowship-trained vascular and endovascular surgeon. She is a co-author of 20-plus journal articles and publications and was recently nominated for an Inspiration Award by the American Medical Association.
This column is sponsored by KSC Cardiology, and the opinions expressed herein may not reflect those of CFHN or its advertisers.