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Carotid Stenosis TreatmentThe AGH Division of Vascular Surgery enjoys a close collaboration with the AGH Stroke Service. As a full-service provider of vascular surgery, surgeons in our division perform a wide variety of open and minimally invasive procedures. In the area of stroke prevention and treatment, we contribute primarily by performing procedures for carotid stenosis. Both carotid endarterectomy and carotid stenting are effective treatment options for carotid stenosis. Carotid endarterectomy is the traditional gold standard method of treating carotid disease. Carotid angioplasty and stenting is a new method that may be a better choice patients under specific circumstances. Our division offers both options, and we choose the procedure based on individual patient characteristics and patient preference. Content
About the AGH Vascular Surgery DivisionVascular disease strikes almost as many Americans as heart disease and cancer do. Yet many patients do not know what the term means. Quite simply, vascular disease refers to diseases of the blood vessels outside of the heart. Many different areas can be affected by vascular disease. The surgeons in our Division provide comprehensive care for patients suffering from this complex disease and works to bring greater understanding and awareness to them and their families. One of the few of its kind in western Pennsylvania, the AGH Vascular Surgery Division is part of the AGH Cardiovascular Center, which includes not only vascular surgery, but also the Cardiac Surgery Center and the Advanced Wound Healing and Lympedema Center. The center brings together a team of physicians, nurses, physical therapists and other health-care professionals to diagnose and treat patients with vascular conditions. This center offers patients the most advanced treatment modalities available for the complete spectrum of vascular disease. Through our multi-disciplinary approach to diagnosis, therapeutic intervention and research, the program offers patients with vascular disease a one-stop shop for their clinical needs with a staff dedicated to providing astute, personalized care. To contact the AGH Division of vascular surgery, please call, fax, email, or write us at: Phone: 412-359-8820 Address: Vascular Surgeons at AGHSatish Muluk MDDr. Muluk has been the division director since May 2003. He came to AGH from UPMC, where he worked for 9 years. He was trained at the Massachusetts General Hospital. Daniel Benckart MDDr. Benckart practices both cardiac (heart) and vascular surgery. He has been at AGH for over 20 years. He was trained at Vanderbilt Hospital. Dean Healy MDDr. Healy has been with AGH for over 10 years. He was trained at Vanderbilt Hospital. Joseph Young MDDr. Young practices both general and vascular surgery. He has been at AGH for over 20 years. He was trained at the University of Pittsburgh. Bart Chess MDDr. Chess practices vascular surgery and trained at Ohio State UniversityConditions
Carotid Stenosis: A Brief PrimerThe carotid arteries carry blood to the brain. Just as atherosclerosis can strike the blood vessels supplying the legs, this same condition can narrow the carotid arteries. When carotid artery disease occurs, the blood supply to the brain decreases. This can cause a stroke, with temporary or permanent loss of functions. Risk FactorsAtherosclerosis is most common in people over age 45. Smoking, high blood pressure, diabetes, family history of arterial disease, high cholesterol levels, sedentary lifestyle, and obesity can raise the risk of atherosclerosis. SymptomsAmaurosis fugax: This is brief loss of vision, for a few seconds to a few minutes, caused by the temporary blockage of small blood vessels in the eye. Sufferers experience a loss or dimming of vision in one eye only, described as a shade being pulled down or up. TIA (transient ischemic attacks): These are mini-strokes and involve a temporary interruption of blood flow in the brain. These attacks can bring temporary paralysis, weakness or numbness in the arms or legs and a loss of speech. They usually end within minutes and can last upto one hour. A TIA is considered a warning sign of a major stroke and should be evaluated urgently in the emergency room because of the short term risk of stroke. One out ten people (10%) who suffer a TIA may suffer a stroke within 2 days of the of the TIA. Stroke: Stroke occurs when too little blood flows to the brain. Cells in that area of the brain die, and can no longer control the related bodily function. The person affected by a stroke might be unable to walk or may experience memory loss. IIt is important to understand that patients with significant carotid disease can feel normal until the time of a stroke, TIA, or amaurosisfugax. In some instances, the surgeon will recommend surgery to prevent a stroke, even when the patient is feeling well. Diagnostic TestingCarotid duplex or ultrasound testing is very useful in diagnosing carotid disease. This noninvasive test uses sound waves to look inside the artery. If a blockage is found, your physician may order an angiogram, which will show the exact location and extent of the blockage. Treatment OptionsWhen tests reveal that less than 70 percent of the artery is blocked, physicians usually recommend aspirin therapy, followed by a duplex study in six months. When blockages are above 70 percent, a surgeon may recommend carotid endarterectomy or carotid stenting to help prevent future strokes. Carotid EndarterectomyPatients who have narrowing of the carotid artery may reduce their risk of future strokes with this procedure. The surgeon makes an incision in the neck overlying the carotid artery — the major blood vessel bringing blood to the brain — and removes fatty deposits from the artery. The patient is usually discharged the day after surgery. Carotid StentingIn some cases, carotid disease can be treated by placement of a stent in the blocked artery. This procedure is done via a catheter inserted into the groin, eliminating the need for an incision in the neck. Carotid stenting is a new procedure, but it holds promise for certain patients. Your physician can help you to decide whether stenting is appropriate in your particular case.
Key Facts About Carotid EndarterectomyWhat is Carotid Endarterectomy?A surgical procedure done through a small (4-6 inches) incision in the neck to remove the blockage inside the carotid artery. When is carotid endarterectomy done?Carotid endarterectomy is performed to reduce the risk of stroke. The goal of treatment is to repair the carotid before the patient has a severe stroke. Even when patients have no symptoms of carotid disease, multiple clinical studies have suggested that the risk of stroke increases when the plaque in the carotid causes severe (greater than 70%) stenosis (or narrowing) of the carotid artery, even among patients having no symptoms. When patients have symptoms (stroke or transient ischemic attack), this can be an indicator of an unstable plaque that is likely to cause a future severe stroke. In this group of patients, carotid endarterectomy if often done even if the stenosis is as low as 50%. AnesthesiaThe procedure can be done under either general or regional anesthesia. At AGH, the vast majority of these cases are done under general anesthesia. Several studies have shown equivalent results regardless of anesthetic type. Patient admission to hospital and length of hospital stayPatients come to the hospital on the day of surgery. Over 90% of our carotid endarterectomy patients go home on the first day after surgery. What are the steps to the operation?Step 1: Expose the carotid artery. How long does the surgery take?The surgery typically lasts for 2 hours. How many carotid endarterecomies are done at AGH?Our division performs over 150 carotid endarterectomies each year (153 cases were performed in 2005). What are the results of the operation?We have experienced excellent results from carotid endarterectomy. A widely used measure of outcomes is the chance of stroke and death from the surgery. At AGH, this rate is less than 1%. This figure compares favorably with the national stroke/death benchmark rates of 2-4%.  This picture shows the right carotid artery exposed at surgery. The patient's feet are to the right of this picture. Notice that the surgeon has placed plastic loops around the key vessels.  In this picture, the carotid artery has been surgically opened. Note that blood flow in the carotid has been stopped by pulling tightly on the elastic loops around the common, external, and internal carotid arteries. This is necessary, so the vessel will not bleed. Remarkably, most people can tolerate stoppage of blood flow in the carotid without injury to the brain. Most surgeons, including the surgeons in the AGH vascular surgery division, use sophisticated methods to monitor the brain function while the patient is under anesthesia. These methods include electroencephaolography (EEG), somatosensory evoked potentials (SSEP), and transcranial Doppler (TCD). If these monitoring studies reveal any reduction in brain function, a shunt can be placed to maintain circulation to the brain even while the carotid artery is occluded.  In this picture, the endarterectomy has been started by using a special metal instrument called an endarterectomy knife. This acts like a delicate spatula that separates the plaque (the diseased inner lining of the artery) from the outer shell of the carotid. Note that this patient has a shunt in place to maintain circulation to the brain even while the carotid artery is occluded.  In this picture, the endarterectomy has been ended. The plaque removal is continued to a point where the vessel is healthy. Sometimes, as in this case, the surgeon will place sutures (called tacking sutures), to stabilize the plaque at the endpoint. The shunt has been pulled out of the way so the surgeon can clearly see the carotid during the plaque removal. The shunt is flexible, so it stays open even when it is bent.  In this picture, the artery has been closed. A patch has been used so as to avoid any narrowing of the artery. The elastic loops have been relaxed, in order to restore flow to the brain. |
