Carotid Artery Disease Screening and Treatment Modalities
Approximately 15 million people suffer from a stroke annually and 1/3 of them die. Most patients have no warning as they may be asymptomatic. Dr. Baqai discusses the potentially easy to miss symptoms of a life-threatening aneurysm.
Featuring:
As a vascular specialist, he believes the key to success is helping his patients build an understanding of their disease process and taking an active role in forming their treatment plans. It is his goal to help raise awareness in the community and focus on prevention and screening of vascular disease. He hopes to be able to provide innovative solutions to challenging vascular problems using state of the art and cutting edge treatment strategies.
Dr. Baqai lives in a suburb of Chicago with his wife and two children. When he is not working, he is engaged with his children who are 5 and 6 years of age doing various indoor and outdoor activities. He also takes care of his elderly parents that live with him as well. He loves to travel with his family and explore new places and cultures. He also enjoys sports and is a big Chicago sports fan and active follower of the Bears, Bulls, and Cubs.
Atif Baqai, MD
Dr. Baqai graduated with a bachelor’s degree from Loyola University Chicago. He was one of four students that was accepted through an Early Assurance Program (EAP) for admission into Loyola Stritch School of Medicine. He then went on to pursue general surgery training from the University of Illinois College of Medicine in Peoria for 5 years before going to University of Miami to complete his vascular surgery fellowship. He began his career his career in vascular Surgery in Dallas, Texas and was then recruited in 2017 to start a vascular surgery program for AMITA health. Since 2017, he has developed and grown the vascular surgery program for AMITA Health to a total of 8 vascular surgeons and is currently recruiting for their ninth surgeon. In addition, this year the program also received accreditation for a vascular surgery fellowship that they will be starting in July 2021.As a vascular specialist, he believes the key to success is helping his patients build an understanding of their disease process and taking an active role in forming their treatment plans. It is his goal to help raise awareness in the community and focus on prevention and screening of vascular disease. He hopes to be able to provide innovative solutions to challenging vascular problems using state of the art and cutting edge treatment strategies.
Dr. Baqai lives in a suburb of Chicago with his wife and two children. When he is not working, he is engaged with his children who are 5 and 6 years of age doing various indoor and outdoor activities. He also takes care of his elderly parents that live with him as well. He loves to travel with his family and explore new places and cultures. He also enjoys sports and is a big Chicago sports fan and active follower of the Bears, Bulls, and Cubs.
Transcription:
Dr Andrew Wilner: Approximately 15 million people suffer from stroke annually worldwide, and a third of them die as a result. Most of these patients have no warning. Eighty per cent of stroke cases occur in asymptomatic individuals. Some of these asymptomatic individuals have carotid artery stenosis, which increases the risk of stroke. Given the asymptomatic nature of carotid artery stenosis, what are the current guidelines for treating it to prevent stroke?
My guest today is Dr. Atif Baqai, Division Chief of Vascular Surgery at AMITA Health, Chair of AMITA Vascular Medicine Subcommittee and Associate Professor of Surgery at the University of Illinois, Chicago, Illinois. Dr. Baqai is going to discuss the diagnosis, prognosis, treatment options, and prevention of carotid artery stenosis.
Welcome to the AMITA Vital Signs podcast. I'm your host, Dr. Andrew Wilner, Associate Professor of Neurology at the University of Tennessee Health Science Center in Memphis, Tennessee. Welcome, Dr. Baqai.
Dr Atif Baqai: Hey, thank you so much for having me. Happy to be here again.
Dr Andrew Wilner: Thanks for joining us, Dr. Baqai. Why don't we get started by defining carotid artery stenosis?
Dr Atif Baqai: Sure. So carotid artery stenosis is basically a narrowing of the carotid artery in the neck and that involves a plaque that builds up over time in patients. And as it continues to narrow, it becomes more and more critical in terms of the perfusion that's occurring to the brain. But even more importantly, when it comes to carotid disease, the significant problem that occurs here is that a plaque can break off and cause a stroke.
Dr Andrew Wilner: Okay. So that sounds bad. What causes this and what can I do to keep it from happening to my two very precious carotid arteries?
Dr Atif Baqai: Right. So the risk factors associated with patients developing carotid artery disease is similar to the risk factors that we associate with anyone developing peripheral vascular disease or coronary artery disease. So, people that have uncontrolled diabetes, high blood pressure, high cholesterol, as well as patients that smoke, that's a significant risk factor for peripheral vascular disease. Therefore, anything that is causing damage to the arteries in one portion of the body, it occurs throughout the body and therefore causes patients to have both coronary artery disease as well as carotid artery disease.
Dr Andrew Wilner: Are there any populations that are at high risk of this?
Dr Atif Baqai: So that's a great question. We have seen that this is more common in males when compared to females, and also this is more common in the African-American population compared to the Caucasian population. So certainly, race and gender play an important role in the development of carotid artery disease.
Dr Andrew Wilner: Now, Dr. Baqai, we talked on another podcast about screening for abdominal aortic aneurysm with ultrasound. It sounds like there might be a lot of people who are at risk for having carotid artery stenosis. Is there a screening process and recommendations or do you just wait for it to get bad and then fix it?
Dr Atif Baqai: Right. So for carotid artery disease, we don't have guidelines in terms of screening that needs to be done. This is more based on physical exam. So, the most common thing that people will find is that when they listen with their stethoscope on their patient's carotid artery, they hear what's called a bruit, which is a high-pitched sound when they're listening to the carotid artery, which is analogous to what I describe to patients, it's like putting your finger over a hose and the more of the hose that you cover, the speed at which the blood is traveling is much faster. And so that's what you're listening for on physical exam. In terms of diagnosing this, whenever you are suspicious that somebody may have carotid artery stenosis, a simple ultrasound, just like for abdominal aortic aneurysms, is all that's needed to diagnose this condition.
Dr Andrew Wilner: What would prompt me then? So physical exam, I listen to the patient, I hear a bruit. It's like, "Okay. Better get an ultrasound." Is there any other symptom or sign that might prompt an investigation?
Dr Atif Baqai: Right. So, patients that are symptomatic, which is symptoms associated with a stroke, right? So if somebody has had an episode where they had difficulty moving one part of their body or one side of their body, if they had weakness in one side of their body and they had difficulty being able to talk, they had any sort of droopiness of the face, if they had this sensation of there being a curtain coming over their eye, where they had a brief loss of vision, those are all the symptoms associated with a stroke. And therefore, if any of those situations arise, a carotid duplex, which is a carotid ultrasound, should definitely be checked in all those patients.
Dr Andrew Wilner: I suspect there are degrees of narrowing, probably most elderly people don't have perfect carotid arteries. How bad does it have to be before it's bad enough to fix?
Dr Atif Baqai: So that depends entirely on whether they're symptomatic or asymptomatic. On asymptomatic patients, we will typically wait for them to be over 75% to 80% before we talk about fixing them. For a symptomatic patient, if somebody's having symptoms and you get a carotid artery duplex, it's variable in terms of when we fix it or not, because it's not always just the degree of stenosis that determines whether something needs to be fixed. Many times patients will have a ulcerated plaque, which you look on imaging and it looks like a very dangerous plaque where that can harbor clot formation and then cause them to be having stroke-like symptoms or having had a stroke. And therefore, in those patients, you would go in and we aggressively fix them so that they don't have a stroke.
One of the risk factors for having a stroke is having had a stroke prior to that or a TIA, that's a common term that gets thrown out, which stands for transient ischemic attack, which is basically a brief episode of them having neurologic dysfunction and it only lasts less than 24 hours and then they're back to normal again. But when patients have had TIAs, they're at a significant risk of having a stroke, especially within the first 30 days.
Dr Andrew Wilner: Okay. Great. Well, let's talk about our options to fix the carotid artery stenosis. You're the vascular surgeon, the patient comes to you, they've had an event. They lost their vision in the right eye for a few minutes and, sure enough, the ultrasound shows a 60%, 70% stenosis, so what are you going to tell them?
Dr Atif Baqai: So we will get CAT scans on these patients to evaluate their anatomy, to look, to see where the plaque starts, where the plaque ends, and get more information from them. And usually, I will review these CTs with the patients when they're in the office with me. And so there's a few ways to go about in fixing it.
The gold standard, which has been the gold standard for the last 50 years, has been to do a carotid endarterectomy. And what that entails is that we make an incision on their neck. We go down to the carotid artery, we open it up, we clean out all the plaque that's within the carotid artery. And then we put a patch on it and close them up. And that has been the way that things have been done for a number of years and it hasn't changed. It's still the same way now.
Another option that patients can have is to have a stent placed and there's a couple of ways for that to occur as well. One of the ways is where patients come in and we access the arteries in the groin and we go up to the carotid artery and we go in and we put a stent in. There's newer technology now, which involves putting a stent in by performing a cutdown right over the carotid artery just above the collarbone. And we make a small incision, we cut down onto the carotid artery there and we stick the carotid artery directly to go up and we put a stent in. This is called a TCAR procedure, which stands for a transcarotid artery revascularization, and is a newer technology that has been present for the past five years or so and shown to have a very low risk of stroke compared to transfemoral carotid stenting.
Dr Andrew Wilner: And that would be because the transfemoral catheter has to wind its way through a lot of arteries before it gets to the carotid and maybe dislodge plaque along the way? Is that right?
Dr Atif Baqai: That's exactly right. So when patients undergo transfemoral carotid stenting, one of the risk factors associated with that is the manipulation of the catheter in the arch of the aorta. And as you know, patients that have carotid artery disease, the have disease in all their plumbing, and therefore there's always plaque present in the arch of the aorta and that can flick off and cause patients to have a stroke during the procedure.
One of the other things that's really interesting about transcarotid artery surgery is that when we put a sheath in to the carotid artery, we'll also put a sheath in to a vein in their groin, into the femoral vein, and we will connect the two sheaths, one that's in the carotid artery to the sheath that's in the femoral vein. And when you connect the two sheaths together, you reverse the blood flow in the carotid artery. So there's no engagement of the plaque in the carotid artery until we have reversal of flow. And because the flow in the carotid artery is reversed, even when we cannulate through the lesion in the carotid artery, the risk of anything breaking off and going to the brain is very low because the flow in the carotid artery is momentarily reversed. And when you go in and put a balloon and stent in, any debris that would break off would not go up to the brain because the flow is reversed in the artery, and that's also one of the reasons why this modality has started to replace transfemoral carotid stenting.
Dr Andrew Wilner: Yes. I remember that a stroke is a complication of actually fixing the carotid stenosis because sometimes little pieces sort of make their way up to the brain as you're scooping them out. And there are little gadgets to put in there, filters and so on to try and prevent that. But even so, a stroke is a potential complication. Is that right?
Dr Atif Baqai: That is right. Yeah. And, therefore, you have to talk to your patients about what are the percentages associated with them having a stroke with whichever procedure you'd choose for them. And so they understand the fact that, yes, our goal of this procedure is to help prevent them from having future strokes, but there is a small chance that they could have a stroke associated with the procedure.
Dr Andrew Wilner: Does your team at Amita Health offer all these different treatment options?
Dr Atif Baqai: Yes. I, myself, perform all three of these procedures and we have pretty much gone away almost completely with transfemoral carotid stenting with now having TCAR procedures. But I do carotid endarterectomies as well as transcarotid artery revascularization, and all my partners do as well.
Dr Andrew Wilner: Well, that's great, Dr. Baqai. I'd like to thank you very much for this interesting discussion about carotid stenosis and all the different treatment options that you offer.
Dr Atif Baqai: Hey, thank you so much. I appreciate it. And glad I'm able to discuss carotid artery disease.
Dr Andrew Wilner: If you're listening to this program and would like to connect with Amita Health physicians to access support services for your practice and more, visit amitahealth.org/pro. I'm your host, Dr. Andrew Wilner. Thanks for listening.
Dr Andrew Wilner: Approximately 15 million people suffer from stroke annually worldwide, and a third of them die as a result. Most of these patients have no warning. Eighty per cent of stroke cases occur in asymptomatic individuals. Some of these asymptomatic individuals have carotid artery stenosis, which increases the risk of stroke. Given the asymptomatic nature of carotid artery stenosis, what are the current guidelines for treating it to prevent stroke?
My guest today is Dr. Atif Baqai, Division Chief of Vascular Surgery at AMITA Health, Chair of AMITA Vascular Medicine Subcommittee and Associate Professor of Surgery at the University of Illinois, Chicago, Illinois. Dr. Baqai is going to discuss the diagnosis, prognosis, treatment options, and prevention of carotid artery stenosis.
Welcome to the AMITA Vital Signs podcast. I'm your host, Dr. Andrew Wilner, Associate Professor of Neurology at the University of Tennessee Health Science Center in Memphis, Tennessee. Welcome, Dr. Baqai.
Dr Atif Baqai: Hey, thank you so much for having me. Happy to be here again.
Dr Andrew Wilner: Thanks for joining us, Dr. Baqai. Why don't we get started by defining carotid artery stenosis?
Dr Atif Baqai: Sure. So carotid artery stenosis is basically a narrowing of the carotid artery in the neck and that involves a plaque that builds up over time in patients. And as it continues to narrow, it becomes more and more critical in terms of the perfusion that's occurring to the brain. But even more importantly, when it comes to carotid disease, the significant problem that occurs here is that a plaque can break off and cause a stroke.
Dr Andrew Wilner: Okay. So that sounds bad. What causes this and what can I do to keep it from happening to my two very precious carotid arteries?
Dr Atif Baqai: Right. So the risk factors associated with patients developing carotid artery disease is similar to the risk factors that we associate with anyone developing peripheral vascular disease or coronary artery disease. So, people that have uncontrolled diabetes, high blood pressure, high cholesterol, as well as patients that smoke, that's a significant risk factor for peripheral vascular disease. Therefore, anything that is causing damage to the arteries in one portion of the body, it occurs throughout the body and therefore causes patients to have both coronary artery disease as well as carotid artery disease.
Dr Andrew Wilner: Are there any populations that are at high risk of this?
Dr Atif Baqai: So that's a great question. We have seen that this is more common in males when compared to females, and also this is more common in the African-American population compared to the Caucasian population. So certainly, race and gender play an important role in the development of carotid artery disease.
Dr Andrew Wilner: Now, Dr. Baqai, we talked on another podcast about screening for abdominal aortic aneurysm with ultrasound. It sounds like there might be a lot of people who are at risk for having carotid artery stenosis. Is there a screening process and recommendations or do you just wait for it to get bad and then fix it?
Dr Atif Baqai: Right. So for carotid artery disease, we don't have guidelines in terms of screening that needs to be done. This is more based on physical exam. So, the most common thing that people will find is that when they listen with their stethoscope on their patient's carotid artery, they hear what's called a bruit, which is a high-pitched sound when they're listening to the carotid artery, which is analogous to what I describe to patients, it's like putting your finger over a hose and the more of the hose that you cover, the speed at which the blood is traveling is much faster. And so that's what you're listening for on physical exam. In terms of diagnosing this, whenever you are suspicious that somebody may have carotid artery stenosis, a simple ultrasound, just like for abdominal aortic aneurysms, is all that's needed to diagnose this condition.
Dr Andrew Wilner: What would prompt me then? So physical exam, I listen to the patient, I hear a bruit. It's like, "Okay. Better get an ultrasound." Is there any other symptom or sign that might prompt an investigation?
Dr Atif Baqai: Right. So, patients that are symptomatic, which is symptoms associated with a stroke, right? So if somebody has had an episode where they had difficulty moving one part of their body or one side of their body, if they had weakness in one side of their body and they had difficulty being able to talk, they had any sort of droopiness of the face, if they had this sensation of there being a curtain coming over their eye, where they had a brief loss of vision, those are all the symptoms associated with a stroke. And therefore, if any of those situations arise, a carotid duplex, which is a carotid ultrasound, should definitely be checked in all those patients.
Dr Andrew Wilner: I suspect there are degrees of narrowing, probably most elderly people don't have perfect carotid arteries. How bad does it have to be before it's bad enough to fix?
Dr Atif Baqai: So that depends entirely on whether they're symptomatic or asymptomatic. On asymptomatic patients, we will typically wait for them to be over 75% to 80% before we talk about fixing them. For a symptomatic patient, if somebody's having symptoms and you get a carotid artery duplex, it's variable in terms of when we fix it or not, because it's not always just the degree of stenosis that determines whether something needs to be fixed. Many times patients will have a ulcerated plaque, which you look on imaging and it looks like a very dangerous plaque where that can harbor clot formation and then cause them to be having stroke-like symptoms or having had a stroke. And therefore, in those patients, you would go in and we aggressively fix them so that they don't have a stroke.
One of the risk factors for having a stroke is having had a stroke prior to that or a TIA, that's a common term that gets thrown out, which stands for transient ischemic attack, which is basically a brief episode of them having neurologic dysfunction and it only lasts less than 24 hours and then they're back to normal again. But when patients have had TIAs, they're at a significant risk of having a stroke, especially within the first 30 days.
Dr Andrew Wilner: Okay. Great. Well, let's talk about our options to fix the carotid artery stenosis. You're the vascular surgeon, the patient comes to you, they've had an event. They lost their vision in the right eye for a few minutes and, sure enough, the ultrasound shows a 60%, 70% stenosis, so what are you going to tell them?
Dr Atif Baqai: So we will get CAT scans on these patients to evaluate their anatomy, to look, to see where the plaque starts, where the plaque ends, and get more information from them. And usually, I will review these CTs with the patients when they're in the office with me. And so there's a few ways to go about in fixing it.
The gold standard, which has been the gold standard for the last 50 years, has been to do a carotid endarterectomy. And what that entails is that we make an incision on their neck. We go down to the carotid artery, we open it up, we clean out all the plaque that's within the carotid artery. And then we put a patch on it and close them up. And that has been the way that things have been done for a number of years and it hasn't changed. It's still the same way now.
Another option that patients can have is to have a stent placed and there's a couple of ways for that to occur as well. One of the ways is where patients come in and we access the arteries in the groin and we go up to the carotid artery and we go in and we put a stent in. There's newer technology now, which involves putting a stent in by performing a cutdown right over the carotid artery just above the collarbone. And we make a small incision, we cut down onto the carotid artery there and we stick the carotid artery directly to go up and we put a stent in. This is called a TCAR procedure, which stands for a transcarotid artery revascularization, and is a newer technology that has been present for the past five years or so and shown to have a very low risk of stroke compared to transfemoral carotid stenting.
Dr Andrew Wilner: And that would be because the transfemoral catheter has to wind its way through a lot of arteries before it gets to the carotid and maybe dislodge plaque along the way? Is that right?
Dr Atif Baqai: That's exactly right. So when patients undergo transfemoral carotid stenting, one of the risk factors associated with that is the manipulation of the catheter in the arch of the aorta. And as you know, patients that have carotid artery disease, the have disease in all their plumbing, and therefore there's always plaque present in the arch of the aorta and that can flick off and cause patients to have a stroke during the procedure.
One of the other things that's really interesting about transcarotid artery surgery is that when we put a sheath in to the carotid artery, we'll also put a sheath in to a vein in their groin, into the femoral vein, and we will connect the two sheaths, one that's in the carotid artery to the sheath that's in the femoral vein. And when you connect the two sheaths together, you reverse the blood flow in the carotid artery. So there's no engagement of the plaque in the carotid artery until we have reversal of flow. And because the flow in the carotid artery is reversed, even when we cannulate through the lesion in the carotid artery, the risk of anything breaking off and going to the brain is very low because the flow in the carotid artery is momentarily reversed. And when you go in and put a balloon and stent in, any debris that would break off would not go up to the brain because the flow is reversed in the artery, and that's also one of the reasons why this modality has started to replace transfemoral carotid stenting.
Dr Andrew Wilner: Yes. I remember that a stroke is a complication of actually fixing the carotid stenosis because sometimes little pieces sort of make their way up to the brain as you're scooping them out. And there are little gadgets to put in there, filters and so on to try and prevent that. But even so, a stroke is a potential complication. Is that right?
Dr Atif Baqai: That is right. Yeah. And, therefore, you have to talk to your patients about what are the percentages associated with them having a stroke with whichever procedure you'd choose for them. And so they understand the fact that, yes, our goal of this procedure is to help prevent them from having future strokes, but there is a small chance that they could have a stroke associated with the procedure.
Dr Andrew Wilner: Does your team at Amita Health offer all these different treatment options?
Dr Atif Baqai: Yes. I, myself, perform all three of these procedures and we have pretty much gone away almost completely with transfemoral carotid stenting with now having TCAR procedures. But I do carotid endarterectomies as well as transcarotid artery revascularization, and all my partners do as well.
Dr Andrew Wilner: Well, that's great, Dr. Baqai. I'd like to thank you very much for this interesting discussion about carotid stenosis and all the different treatment options that you offer.
Dr Atif Baqai: Hey, thank you so much. I appreciate it. And glad I'm able to discuss carotid artery disease.
Dr Andrew Wilner: If you're listening to this program and would like to connect with Amita Health physicians to access support services for your practice and more, visit amitahealth.org/pro. I'm your host, Dr. Andrew Wilner. Thanks for listening.