Narrator: Coming up on Mayo Clinic Q&A,
Dr. Luis Savastano: Most of the time, there are no signs or
symptoms. And that is a problem because it is a silent disease
that progresses over time until there is an acute rupture of the
plaque. And when that happens, a clot can form in the surface and
the clot can be pushed downstream to the brain, and
that is what causes the stroke.
Narrator: These clots can form if you have carotid artery
stenosis, a disease where fatty deposits clog the blood vessels
that deliver blood to the brain. This blockage increases your
risk of stroke. But with early detection and new therapies,
injury to the brain can be prevented.
Dr. Luis Savastano: And by looking at the wall of the
artery, with basically next generation imaging tools, we can
see the root cause of stroke. And in those patients where we
can find the problem, we can really help them by targeting
our therapy.
Dr. Halena Gazelka: Welcome, everyone to Mayo Clinic Q&A. I'm
Dr. Halena Gazelka. We are going to learn something together
today and the topic is carotid stenosis. Carotid artery
stenosis is narrowing of the large arteries or vessels on the
sides of the neck that carry blood to the head and the brain.
This narrowing is usually the result of a buildup of fatty
deposits known as plaque within the arteries. Stenosis can
worsen over time to completely block the artery and cause what
we know as strokes. So, what are the signs and symptoms and how
can carotid artery stenosis be treated? Well luckily, we have
an expert here to talk to us today. Dr. Luis Savastano is a
neurosurgeon at Mayo Clinic. Welcome Luis, thanks for being
here.
Dr. Luis Savastano: Thank you, my pleasure.
Dr. Halena Gazelka: Wonderful to have you here to talk to us
about this today. Thanks for being here. Luis, tell us how
common is carotid artery stenosis?
Dr. Luis Savastano: Yes, carotid artery stenosis is very common,
especially in elderly patients. And about five to 7% of patients
75 years or older are going to have carotid stenosis. It is
important to remember, that is one of the most common reasons
for stroke and is causing at least 25% of all the strokes.
Dr. Halena Gazelka: Wow, that is sounds very common. And how
would someone know if they had carotid artery stenosis? Are
there signs or symptoms?
Dr. Luis Savastano: Yes, most of the time, there are no signs or
symptoms, and that is a problem because it is a silent disease
that progresses over time until there is an acute rupture of the
plaque. And when that happens, a clot can form in the surface and
the clot can be pushed downstream to the brain, and
that is what causes the stroke. And most of the signs and
symptoms of stroke patients are going to be difficulties moving
one side of the body, or feeling, or some language
problems, difficulties to talk or to understand.
Dr. Halena Gazelka: How do you diagnose carotid artery
stenosis?
Dr. Luis Savastano: There are two settings where carotid
artery stenosis is diagnosed. One is in patients that have a
family history of carotid artery disease, they are smokers, and
they have high blood pressure and have high cholesterol,
diabetes, and the primary care provider orders basically
screening tests. That can be an ultrasound of the carotid or a
CAT scan of the arteries of the neck. And most of the time,
those are asymptomatic carotid stenosis. The other circumstance
is when patients present to the hospital with stroke symptoms.
And in the workup of the root cause of the stroke, there are
images of the carotid obtained showing the narrow.
Dr. Halena Gazelka: Dr. Savastano, it sounds to me like
the risk factors for carotid artery stenosis may be fairly
parallel to those for coronary disease or heart disease. Is
that true?
Dr. Luis Savastano: Absolutely. Keep in mind that
atherosclerosis, which is the reason of the narrowing, or
these plaques, is a systemic disease, meaning that happens
everywhere in the body, especially in patients that are
basically smokers, high blood pressure, they have poorly
controlled diabetes, and the same that is happening in the
coronary arteries in the heart happens in other arteries in the
body, such as the carotid arteries.
Dr. Halena Gazelka: So, if a person is known to have coronary
disease, they should know that they could be at risk for this
as well.
Dr. Luis Savastano: They could be at risk. Yes, it will be
reasonable to do a screen for that.
Dr. Halena Gazelka: As ascreening test, are there any
blood tests that can be screening tests, or is it
imaging tests like the ultrasound?
Dr. Luis Savastano: There are blood tests that can be done but
those are mostly for the systemic risk factors such as
the cholesterol level, the lipid levels, the blood sugar level.
I think is important if patients are in those risk factors to
talk with the primary care physician to see if they are
good candidates for health screening.
Dr. Halena Gazelka: Okay, so supposing that someone does not
have a diagnosis or is unaware of this, what can happen if it
goes untreated?
Dr. Luis Savastano: Yes, there is a potential that the plaques
are going to progress over time. And they may eventually rupture.
When that happens, there is a clot forming in the surface, and
the clot can block the artery, or the clot can fragment and go
to the brain causing a stroke.
Dr. Halena Gazelka: So how do you prevent that? What are the
treatment options?
Dr. Luis Savastano: So, it's important to consider that the
first thing to do is to improve the medical management of the
patients. By that I mean living healthy lifestyles, exercise,
having a healthy weight, controlled diabetes. If the
patients are diabetic, keep the cholesterol levels down and
control the blood pressure, and of course, stop smoking. And
once the plaque becomes symptomatic, or the patient is
having a stroke, if there is a significant narrowing, the
treatment on top of the medical management includes basically
repairing the artery. And overall, there are three
techniques that can be used. And one is basically removing the
plaque through surgery, which is called carotid endarterectomy.
The second option is to place a stent through a catheter placed
in the groin or in the wrist, that is advancing towards the
carotid. And the last option which is the most recent is
placing a stent directly from an access into the carotid artery
in the neck which is called transcarotid artery
revascularization.
Dr. Halena Gazelka: Interesting. So, with the surgery, you
actually make an incision in the neck and go into the artery.
Dr. Luis Savastano: Exactly, yes. And then basically, the
artery is exposed and is open, and then the plaque is
completely removed. And then the artery is basically closed back
up to re-establish the flow to the brain.
Dr. Halena Gazelka: Okay. Or you can go through the grind and
put a stent in.
Dr. Luis Savastano: Exactly right.
Dr. Halena Gazelka: And with the third option, how big is the
incision, or the entry point into the neck?
Dr. Luis Savastano: The incision is about one inch in size, and
it's kind of a hybrid approach. It is a combination between an
open surgery and a stent intervention.
Yeah, I think there are several nuances to discuss, basically to
decide what is the best option for a patient. It is important
to consider that the three are very good options. They are very
effective and have a very good safety profile. But there are
certain features within basically each patient that
makes one option better than others.
Dr. Halena Gazelka: Okay.
Dr. Luis Savastano: So, it's always good for patients to try
to go to centers that are very familiar with all the available
options.
Dr. Halena Gazelka: Can you give us an example of why one
approach might be preferred over another?
Dr. Luis Savastano: Yes, for example endarterectomy, which is
the open surgery, is the oldest and the most established
technique. Having said that, the neck needs to be relatively
healthy to do surgery. Now, for example, if the patient has a
history of radiation in the neck or has a history of multiple
neck surgeries for other things such as cancer, the dissection
to expose the artery is more challenging. So, in those cases,
it's more convenient for patients to have the stenting.
This will happen about where is the location of the plaque,
sometimes the plaque is kind of the middle of the neck, I mean,
it is relatively straightforward to access surgically, but
sometimes it's very high behind the mandible, which is more
difficult to get a good approach.
Dr. Halena Gazelka: Interesting.
Dr. Luis Savastano: In this case, stenting is preferred.
Dr. Halena Gazelka: Very interesting. And how do patients
know, Luis, if they are getting the right care for themselves
for carotid artery stenosis?
Dr. Luis Savastano: Yes. So, I would start saying that when
patients are having symptoms for stroke and they're diagnosed
with a stroke, it is critical to find the root cause of the
problem. Because if you cannot target your treatment, it is
unlikely that you're going to provide the best benefit to
patients, and the benefit is preventing the future stroke.
And at Mayo, we have clinics which are multidisciplinary and
basically, they have specialists which involves neurology, stroke
neurology, cardiology, vascular surgery and neurosurgery where
we work together to understand why a patient had a stroke. And
once when they understand that the next question is how can we
best prevent another stroke from happening? And that is a
discussion that needs to happen within teams. And based on the
consensus, then we find the best option that we have for the
patient. And that is what we offer them.
Dr. Halena Gazelka: That team-based care sounds like a
great option for getting all of your information and care in one
spot.
Dr. Luis Savastano: Yes, absolutely. And the other thing
to consider is that, in addition to having a streamlined process
to provide that basically multidisciplinary care, it is
important to understand that there has been an evolution of
the techniques and the tools that we use to find the root
cause of a stroke. For example, for many years, we have thought
about narrowing of the arteries as the main problem, what we
learned in the last decade or so was that, in addition to the
narrowing, the reason of the narrowing of the artery is
critical. And if there is, for example, a hemorrhage within the
plaque or bleeding within the plaque, we can prevent strokes
by fixing the artery even if there is no significant stenosis
or narrowing.
Dr. Halena Gazelka: Interesting.
Dr. Luis Savastano: To see the plaque, you need the technology,
and at Mayo we have kind of specialized MRIs to see those
problems in the arteries.
Dr. Halena Gazelka: Like so many things, it's important, how many
of these surgeries you do and how many cases you see I'm
certain.
Dr. Luis Savastano: Yes, exactly. So now these are well
established surgeries and interventions. But it's
important for the centers to maintain a complication rate of
3% or less. And that's something that it's tightly regulated.
And of course, the more you do the safer it is for the
patients.
Dr. Halena Gazelka: That's very interesting. Anything else you'd
like to share today, Luis.
Dr. Luis Savastano: So, for a very long time the focus of our
attention in carotid artery disease has been on the degree
of narrowing. And what we have found, and we're doing with our
patients now is to look at the wall of the artery in addition
to the degree of narrowing, and by looking at the wall of the
artery with basically next generation imaging tools, we can
see the root cause of stroke in patients that otherwise are
labeled with strokes of unknown reason. I mean, those patients
where we can find the problem, we can really help them by
targeting our therapy, both medically and with surgical
interventions.
Dr. Halena Gazelka: I think it's really interesting you mentioned
that because I remember being an anesthesia resident, and, you
know, reading patients charts who were going to have carotid
endarterectomy, and the main decision making seemed to be
what the ultrasound or other imaging study showed, was the
percent of blockage of their artery.
Dr. Luis Savastano: Yes, exactly. And there has been a
dogma within basically stroke. And at Mayo we're really
pioneering basically a change in the dogma. And we have basically
the largest published series of patients undergoing surgery for
minimal to no stenosis and showing that we can really
prevent recurrent strokes. And at the same time, here at Mayo
we are the principal investigators of an NIH trial.
specifically looking at interventions for nonstenotic
carotid artery disease.
Dr. Halena Gazelka: How interesting. Thank you so much
for sharing with us today.
Dr. Luis Savastano: Absolutely. My pleasure.
Dr. Halena Gazelka: Our thanks to Dr. Luis Savastano for being
here today to talk to us about carotid artery stenosis, and its
diagnosis and management. I hope that you learned something. I
know that I did. We wish each of you a very wonderful day.
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