The major blood supply to the brain is supplied by the carotid arteries, which are located on either side of the neck. An artery is normally smooth, allowing blood to flow freely. Arteries may become blocked by atherosclerosis or “hardening of the arteries”. You may or may not have any symptoms. Your doctor or health care provider may listen to your neck and hear a “bruit”, which is due to turbulent blood flow. Ulcers may also form inside the artery. These ulcers have a rough surface which may cause particles of atherosclerosis or blood clots to break loose into the circulation to the eye or brain. These may cause a TIA (mini stroke), or stroke. We as a team are able to diagnose, evaluate, and treat carotid artery disease.
Transient Ischemic Attack (TIA) or “Mini Stroke”
This happens due to a brief decrease in blood flow to the brain. Symptoms are temporary, lasting no longer than twenty four hours.
Signs and Symptoms of TIA
- Difficulty understanding or writing words
- Slurred speech
- Changes in vision, temporary loss of vision (described as a shade being drawn down in from of eyes).
- Weakness or loss of function of the arms or legs involving one side of the body, face or mouth
- Loss of coordination
Cerebral Vascular Accident (CVA) or Stroke
A CVA occurs when symptoms of a TIA do not get better or go away in 24 hours and may worsen through a series of episodes. A stroke may occur without warning and may be mild or severe, often occurring suddenly.
Signs and Symptoms of a CVA
Paralysis (inability to move) / Facial or mouth drooping on one side of the body
- Loss of all or part of vision
- Difficulty in speaking and/or understanding written or spoken words
- Difficulty swallowing
- Loss of consciousness
Non Invasive Testing
You may eat and drink before the exam and take your usual dose of medications unless instructed otherwise.
Ultrasound - This type of test uses ultrasound to send high frequency sound waves into the artery which are reflected by moving red blood cells. The vascular technician will place a hand held transducer (probe) on your skin with some gel to perform the test. This test takes about fifteen minutes to complete.
Magnetic Resonance Angiography (MRA) - This test is often used to check for blockages of the arteries in your neck. It uses a large scanner with a powerful magnetic field to produce images based primarily on the water content of the body’s fluids, organs, and tissues. It does not use needles or dye, and it is painless. The test takes about thirty to sixty minutes and requires you to lie very still in a noisy tube-like machine. Let you doctor know if you are claustrophobic (cannot stand to be in small spaces) before taking the test. This test cannot be done on people who have metal implants, such as metal plates, pacemakers, orthopedic screws, or cerebral aneurysm clips. It is okay if you have fillings in your teeth, however you must remove any jewelry or watches before the test.
Invasive Arterial Testing – Angiogram
An angiogram is an x-ray of your arteries. This test is done to determine the exact location of disease within your arteries. It is performed by a team of physicians, physician assistants, nurse practitioners, nurses and technicians. You will meet with someone prior to the test. They will review the procedure, possible side effects and ask you to sign a consent form. Blood work is drawn before the test to determine the ability of your blood to clot and your kidney function.
You will be required not to eat solid foods eight hours before, and will need to stop liquids three hours before the angiogram. You will receive specific instructions regarding your medications, insulin and blood thinners from your doctor or nurse before the test.
You will not be able to drive for one day following the procedure. Therefore, you will need to make arrangements for someone to drive you home.
If you are a diabetic please check your fingerstick the morning of your procedure.
For angiograms, an intravenous catheter is inserted into a vein in your arm and you may be given intravenous fluids and/or medications to help you relax. The femoral artery in your groin is most often used to insert a catheter in which to inject dye; however the artery in your inner elbow or armpit may also be used. The area is first shaven and then numbed with a local anesthetic.
A catheter is inserted into the artery and dye is injected and then x-rays are taken. You will feel a warm sensation in your body as the dye is injected. When the catheter is removed, the physician will apply pressure to the insertion site for approximately fifteen minutes. The procedure takes one to one and a half hours to complete. After the procedure you will need to be on bed rest with the affected leg or arm straight for four to six hours. This is to prevent any bleeding at the puncture site.
This whole procedure takes approximately two to three hours. If you need to have any other testing we will try to schedule it the same day. If you are to be admitted the day before your surgery the above tests will be performed when you are admitted.
For same day surgery the hospital will notify you the day before your surgery after 2:00pm to tell you what time to report to the hospital. If your surgery is on a Monday you will be notified the Friday before your surgery.
You will be admitted on the Vascular Surgery service under the care of the Vascular Surgeons. Your referring physician and any other medical specialist will be notified of your admission and surgery dates. If an angiogram is ordered on the day of admission, you should report to the specified area at the instructed time. Otherwise, you will receive a phone call from the Admitting Office with instructions for your arrival. If you do not receive a phone call by 12:00 noon, please contact our office.
If you are to be admitted the day of surgery, you will need to have pre-admission testing prior to your scheduled surgery. At pre-admisson testing you will meet with an anesthesiologist, and nurse. You will have blood work, urine testing, EKG, and a chest x-ray. This whole procedure takes approximately two to three hours. I you need to have a MRA or any other tests we will try to schedule them the same day.
The hospital will notify you the day before your surgery after 2:00pm to tell you what time to report to the hospital. If your surgery is on a Monday, you will be notified the Friday before your surgery.
TREATMENT OF CAROTID ARTERY DISEASE
Risk Factor Modification
Studies have been done on people with atherosclerosis; this is to help predict which people will be at a high risk of developing this disease. These people usually have one or more of the following risk factors:
- Hypertension (high blood pressure)
- High Cholesterol
- Family history of atherosclerosis
It is important to try and eliminate or minimize the risk factors that you can control, such as smoking, obesity, diabetes, and your activity level.
CAROTID ARTERY STENTING
Stenting of the carotid arteries is an evolving minimally invasive approach for treatment of carotid artery stenosis. Through new innovations, research techniques, and National Institute of Health trials, we are able to offer this advanced intervention on select patients.
Carotid stenting is generally considered for patients with recurrence of stenosis after previous carotid surgery, previous neck surgery, and/or radiation to the neck region.
The procedure is quite similar to the angiogram except for the following, a small catheter with a balloon is inflated and pushes the plaque against the inner wall of the artery making room for more blood flow. Then a stent is left in place to keep the artery dilated. The balloon is deflated and the catheter is removed. Dye is then injected and x-ray pictures are taken to make sure the artery has opened adequately. You will stay overnight in the hospital.
An antiplatelet agent is usually given prior to the procedure and for some time after, 1 – 3 months or longer. These are used to reduce the risk of platelet aggregation (clumping) and thrombus (clot) formation. Plavix and aspirin are common antiplatelet agents that are generally prescribed
Surgery will depend on the extent of blockage and the associated symptoms that you are experiencing. Your doctor may recommend periodic ultrasounds to monitor the progression of your diseases before recommending surgery.
What can I expect before surgery?
Someone from the anesthesia department will speak to you before surgery and will discuss the type of anesthesia that will be used with you, called a Cervical Block, and have you sign a permission form. You will not be allowed to eat for eight hours prior to surgery. Someone will review your medications to see which, if any, you can receive the morning of surgery.
What can I expect during surgery?
Carotid Endarterectomy – This is the name of the surgery to repair the blocked carotid artery. You are awake for the surgery. You will be given medication to numb the side of your neck to be operated on and some medicine to help you relax through an IV. This type of anesthesia minimizes your risks associated with surgery. It is important that your are awake during your surgery so the doctor and anesthetist can monitor your neurological status, or brain function. If you lose any function of your brain, the doctor will direct more blood to your brain with a shunt. A shunt is a tube that can channel blood from below the blockage in your artery to above the blockage. Once the surgery is completed, the shunt is removed.
You will have sterile drapes over your face and an oxygen mask around your mouth. After your neck is numbed, a small incision about four inches will be made below the level of the jaw. Once the carotid arteries are exposed, clamps are placed above and below where the blockage or plaque is located. The artery is then opened and the plaque is carefully removed. The artery is then stitched closed as is the muscle in your neck. The skin is closed with skin staples, and a bandage is applied over the area. Some patients also have a small bulb drainage device inserted at the bottom of their incision to drain away any excess fluid. The entire surgery takes about two hours.
What can I expect after surgery?
After surgery you will be taken to the Recovery Room to be closely monitored for around two hours. Then you will go to a hospital room. During this time the nurse will be checking your blood pressure, pulse, and dressing frequently. They will also shine a flashlight in your eyes to check your pupil response, ask you simple questions, ask you to move your arms and legs, grasp their hands, smile, and wiggle your tongue from side to side. This is all done to make sure that both sides of your brain are functioning effectively and that you are thinking clearly.
After the cervical block wears off you will be able to eat and drink. Your nurse will check your gag reflex to assure that you will be able to swallow without any difficulty and you will be allowed to eat. You will be able to get out of bed the evening of your surgery.
Post-Operative Days 1 and 2
Your dressing will be removed and if there is no new damage from the incision it will be left open to air. The staples are removed from your incision and small pieces of tape, steri-strips, are applied over the incision. These will fall off by themselves in one to two weeks. It is normal to have some swelling and numbness at the operative site. If a drain was inserted during our operation, it too will be removed and a small dressing applied. This dressing may be removed after twenty four hours.
You will be discharged if you are medically and physically ready. The time for discharge is 10:00am
- What should I expect once I go home?
- When you return home from the hospital you may feel tired. You are encouraged to do light exercise such as waling.
- If you have a history of hypertension (high blood pressure) you will need to have your blood pressure checked everyday during the first week you are home.
- Mild swelling around the incision
- Numbness around the incision and jaw – this may last a few months but will improve with time.
- Mild Headache.
- It is okay to shower, but don’t have a direct stream of water on your incision. Pat the area dry.
- If there is drainage from your incision apply a gauze dressing.
- No heavy lifting (nothing heavier than a phone book) for two weeks.
- No driving for two weeks.
What to Report
- Redness that extends away from the incision
- Foul smelling drainage
- Temperature greater than or equal to 101f for 24 hours
- Elevated blood pressure, greater that or equal to 170/90
- Severe headache
- Any of the symptoms of a TIA or CVA
It is important to keep your follow up appointments. Ultrasounds of your carotid arteries will be scheduled periodically to monitor the surgery that was done. If any problems occur, do not hesitate to call. There is always someone available to answer your questions.