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I've performed over 1600 carotid and arteritic procedures at Johns Hopkins over
the years, but without question the most rewarding and gratifying part of
my practice in terms of carotid disease, is reassuring patients that they
don't need an operation and they're not at high risk of stroke.
Stroke, in my opinion, is the
most devastating complication of cardiovascular disease.
It devastates lives.
One year after stroke, two-thirds of
survivors are left with significant functional deficits.
That's our third leading cause of death, our second leading cause of
dementia and the number one cause of adult disability in America today.
And patients are terribly scared when they hear the word stroke.
I see lots and lots of patients, almost on a weekly basis,
who have had a duplex scan, often in a community screening, a study.
And they have a piece of paper that says
they have carotid disease and they're at risk of stroke.
And we see them.
We evaluate them comprehensively, we get a
duplex scan in our accredited vascular laboratory
and find that they only have modest
disease at most and they're best treated medically.
I've got patients like that I've been following for ten or 20 years.
I enjoy performing carotid surgery, but it's terribly gratifying
to be able to put someone's mind at ease.
Tell them they don't need an operation, and they're not at risk of stroke.
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The term vascular surgeon is really a misnomer because
vascular surgeons do much, much more than conventional surgery.
We diagnose the condition, we perform the duplex scans in our vascular laboratories.
And we perform both carotid and
arterectomy, and carotid angioplasty and stent procedures.
I think it's, it's sort of important to emphasize
that only when a patient sees a physician or group
of physicians who have all the tools in their
toolbox, we have all of the modalities of treatment available.
Only then will that patient be guaranteed that they're gonna get the treatment that
they're most in need of rather than
a particular treatment that a particular specialist offers.
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The carotid arteries are the two major blood vessels in the neck,
one on each side that deliver blood and oxygen to the brain.
Carotid artery disease refers to the progressive blockage
of these vessels due to the build up of
plaque made up of cholesterol, calcium, fibrous tissue and
blood clots that deprives the brain of adequate oxygen.
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There are over 700,000 strokes that occur each year in the United States.
And carotid artery disease is one of the
most important and completely preventable causes of stroke.
Stroke occurs when these blockages in the carotid
artery limit blood flow so that cell death occurs.
Or when bits of the plaque break off and lodge in the tiny vessels in the
brain, again limiting oxygen supply, leading to cell
death and the development of a clinical stroke.
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The prevalence of carotid artery disease increases with advancing age.
Although it can occur in younger individuals,
most patients are over the age of 65.
Other factors that contribute to the development of carotid
artery disease include high blood
pressure, hypertension, elevated cholesterol levels.
Diabeties and certainly cigarette smoking.
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The most appropriate treatment for a patient
with carotid artery disease depends on two factors.
First, the severity of the blockage itself and the patient's symptomatic status.
The severity of the blockage is best determined
by performance of a carotid duplex ultrasound examination.
This is a noninvasive, relatively quick, and relatively inexpensive test
that not only tells us how severe the artery is blocked.
But also allows us noninvasively to examine the plaque, and
the character of that plaque, which has future prognostic significance.
The other issue is the patient's symptomatic status.
Most patients with carotid disease are completely asymptomatic when they present.
And when we know about them, it's typically because they've had a [UNKNOWN]
or a sound in the neck that was picked up by a stethoscope.
For those patients, unless the blockage is
really severe, the optimal treatment is medical management.
This includes the use of aspirin which is
a powerful anti platelet or anti clotting drug.
Use of stat medications which not only
lowers cholesterol levels but actually stabilize the
plaque itself and has been shown in
numerous studies to reduce stroke risk long term.
And good blood pressure control and again certainly stopping smoking.
On the other hand, once a patient has become symptomatic, that is either had a
stroke or a so called mini stroke or
TIA transient ischemic attack, then intervention is required.
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The standard conventional treatment for symptomatic carotid
disease and also asymptomatic disease that is
very, very severe, that is typically greater
than 80% blocked, is a carotid endarterectomy.
This operation is really the gold standard treatment for carotid disease.
It's been around, it's been performed for more than 50 years.
And it's been highly studied and very well perfected.
In this operation the surgeon makes an incision over
the artery, opens the vessel and directly removes the plaque.
And then repairs the artery.
It can be performed either under general anaesthesia or with local anaesthesia
by numbing the skin, depending upon the surgeon's and the patient's preference.
It takes about an hour to do the procedure, and recovery is very quick.
Most patients are discharged the day after surgery.
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An alternative to carotid endarterectomy today is carotid angioplasty and stenting.
This is generally reserved for patients considered to be at too high risk
for open surgery and it's, it's an
approach that is still under clinical investigation.
In this procedure, the skin in the groin is numbed up with a local anaesthesia,
a needle is introduced, a catheter is
introduced, and threaded up into the carotid artery.
Dye is injected, and a picture on our turogram
of the carotid artery is obtained, and then a
balloon is inserted and dilated up, to open the
blockage, and then a stent is usual, usually placed.
They hold the blockage open and again after
carotid angioplasty and stent and recovery is very quick.
Most patients go home the day after surgery.
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Recovery from carotid endarterectomy is very rapid.
Really, patients resume their normal activities just a
day or two after being discharged from a hospital.
The one exception is because there's a, an incision in the neck and it may be
a bit sore, we encourage patients not to
drive themselves for about a week or ten days.
Because changing lanes might be a little bit of a challenge in similarly after
carotid angioplasty your stem procedure because the
groin might be a little bit sure.
Again we ask patients not to drive for about a week after the
procedure but generally patients immediately return to
the normal quality and status of life.
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Although we perform these procedures to prevent stroke, stroke
is one of the potential complications of these interventions.
In a recently completed NIH trial, the Crest
trial, the incidence of stroke was about 2%.
That is one in 50 patients who had a carotid endarterectomy versus
4%, one in 25 patients who underwent a carotid angioplasty and stent procedure.
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In general, I like to see my patients a few weeks after surgery just to make sure
the incision's healing after a carotid endarterectomy or the
groin looks okay after a carotid angioplasty extent procedure.
And then, we have the patients return once a year,
and at that time obtained a carotid duplex ultrasound examination.
Not only to look at the artery that we
treated, but also to look at the other carotid artery
on the other side of the neck to make
certain that it's not developing new disease down the line.
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It is very important that the carotid
duplex scan be performed in an accredited laboratory.
Ultrasound machines are available in many physician's offices, and healthcare
clinics, and walk in clinics, and these are very critical tests.
The decision as to how we treat a patient is
dependent upon the information that comes out of these tests.
And only when a patient is evaluated in a truly
accredited vascular laboratory that has to meet very rigorous criteria can
they be certain that the information that they're being given
is truly accurate in terms of determining their most appropriate treatment.
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And as chief of the division of vascular surgery and
endovascular therapy, I'm most proud of the team that we've recruited.
Our vascular team at Johns Hopkins, all of use share a common vision.
We believe our mission is not to take care of disease.
Our mission is to take care of people.
We're all committed to one goal, that is to do the
most appropriate thing to optimize the vascular health of our patients.
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Johns Hopkins has a well deserved reputation
as an outstanding center for research and teaching.
And we're an international center of excellence in clinical care.
Diagnosing and treating the entire gamut disease from
the various attack to the every day routine processes.
I think sometimes what gets lost in this well-deserved reputation
is the human touch inherent in the care that we deliver.
Johns Hopkins physicians truly care about patients as people.
And that's something that we're most proud of.
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