Intro: This is BayCare HealthChat. Another podcast from BayCare Health System.

Prakash Chandran (Host): Welcome to BayCare HealthChat. I'm Prakash Chandran. Today, we'll be talking about carotid stenosis, which is the narrowing of one of the carotid arteries located on each side of the neck, just below the jawline. It usually is caused by plaque or fatty deposits and can result in reduced blood flow to the brain, and in some cases, a complete blockage of the artery. Joining us today is Dr. Yves A. Gabriel, a vascular surgeon at BayCare Health System. Dr. Gabriel, thank you so much for joining us today. I really appreciate your time. Now, I gave the textbook definition up at the top, but I'd love for you to tell us a little bit more about what carotid stenosis actually is.

Yves A. Gabriel, MD (Guest): Sure. It's a pleasure to be here. And I thank you for the opportunity. Carotid artery stenosis is really what you actually discussed. And the simple form is a blockage in the artery that leads to the brain and as the blockage gets worse or what we call a higher degree of stenosis or blockage, that actually starves the brain of oxygen.

And when the brain is starved of oxygen, it starts to die, which manifests itself as a stroke. And there are different types of stroke that can develop based upon the location of the blockage and which parts of the brain are affected.

Host: I see. And, you know, I think a lot of us have heard of coronary artery disease before. Is carotid stenosis a form of this?

Dr. Gabriel: Yes, it is. As a matter of fact, the same factors which lead to coronary artery disease are the ones that also lead to carotid artery stenosis, such as people who smoke, diabetics or patients who have high cholesterol associated with morbidity, obesity. Those are the different things that can cause actually both. So, carotid artery stenosis is a variation of the same type of disease that can occur in coronary artery disease.

Host: Okay. Understood. And so, typically the demographics of people who are more at risk, you mentioned people who smoked, diabetics is generally the exact same for carotid stenosis. Is there anything that's different?

Dr. Gabriel: No, it's pretty much the same. As a matter of fact, the patients who I see before we operate on them, we always make sure that we go back and we check out the heart, because you could get fooled into thinking, that well the patient is awake, they're walking, they're doing pretty good; they can't possibly have coronary artery disease, but because of that association, we make sure that we check that first because unrecognized coronary artery disease can lead to issues during surgery with the heart. And you definitely want to make sure that you catch that.

Host: Got it. So can you talk to us a little bit about the signs or symptoms that one might have carotid stenosis?

Dr. Gabriel: Absolutely. The two ways that the carotid artery disease can lead and present itself is number one, some patients come in with what we call a TIA or a stroke. A TIA is any neurological event that happens under 24 hours. Whereas a stroke is a more permanent neurological deficit. So some of these patients come in and they have difficulties talking. They have difficulties walking or even difficulties moving their arms where a family member or someone who's around them clearly recognizes that that patient is not themselves. And then they've come in and then that's one of the ways that we could identify it. Another way that we can identify it as well is when patients are actually going to have another major operation and someone actually checks it, as we were alluding to with coronary artery disease. So if they're going to have heart surgery, they get a test to actually look to see if there's also associated carotid artery disease. So those are the two main ways that we find these patients and identify them.

Host: And, obviously a blockage in the artery that leads to the brain, that sounds serious. So can you talk about some of the consequences of this disease, if not diagnosed and treated immediately?

Dr. Gabriel: You know that’s an excellent point. I think that's one of the things that we always like to mention. Just the awareness that in the specific patients that we discussed, you have to recognize it because you can actually do something if you find it. And at the same time, if you don't find it, the effects are so disabling. There are a lot of patients who simply die. The brain is starved of so much oxygen that it's not able to recover or there are some patients who actually have what we call morbidity, which is that they have a disabling stroke and really have difficulties eating, difficulties talking, or even difficulties walking, which can clearly affect their quality of life afterwards.

Host: Okay. So the most extreme case is unfortunately, death, but even more mild cases can potentially handicap someone for the rest of their lives. Is that correct?

Dr. Gabriel: Absolutely. When I do these surgeries, I think that's one of the things that always stands out in my mind in terms of the excellence and focus and dedication that you have to bring to the surgery, because it can leave them permanently damaged with a very poor quality of life. So you can imagine someone who's walking around daily and they're working and then they suffer a stroke and all of a sudden now they're unable to even talk and communicate with their family, or they're even unable to walk, to actually enjoy their quality of life. So we recognize it, and that definitely leads us to be more focused and dedicated to not only finding it, but treating it, but at the same time, treating it well so that the patients can recover and continue on with a good life.

Host: Now you talked about the importance of getting to it early, and you also talked about the different ways that someone comes in and you recognize it. How can someone be proactive and get it diagnosed earlier? Is this something that they can check for at an annual checkup with their primary care provider? Can you talk to us a little bit about that?

Dr. Gabriel: Sure. I think the easiest way is identifying their risk factors. Someone who has high cholesterol, someone with diabetes, someone who either themselves is or was a smoker or who is associated with smoking; knowing that those risk factors can lead to it as the first step. Once you identify that you are at risk for it then definitely talking to your primary care physician in terms of what are the chances of them having it is important. From the primary care physician, they could determine what tests are appropriate, to proceed with to identify if there is a blockage or not.

The simplest one is an ultrasound. And then based upon the ultrasound results, they could determine if any other studies or a referral to a vascular specialist is indicated.

Host: Okay. And I guess that leads me to my next question. Obviously, you're a vascular surgeon, so you're probably dealing with the most acute cases, but I'm curious as to the first line treatments that are available before it gets to surgery.

Dr. Gabriel: That's such an important point, because as you said, I am a vascular surgeon and a lot of times the patients come to me and they're apprehensive about seeing me because they think that surgery is the first option. Interesting enough, surgery is not the first option. As you alluded to, if the patients come in with severe disease, then yes, surgery becomes an option.

But the first option is just medical management. If you have a high cholesterol, putting the patients on medications to decrease that cholesterol, if they have a high chance of a clotting, we put them on medications to decrease the chance of clotting, if their heart has a funny rhythm, and it's beating inappropriately, we put them on medications to slow that heart down.

So medical management is the first one, even in terms of what we call lifestyle risk factor modification, encouraging smoking cessation, regular exercise regimen, and diet. From there yes, based upon the degree of stenosis the more complicated patients we do go on to recommend surgery. But treating them conservatively at the beginning is the first step.

Host: So I imagine that the technology has advanced quite a bit in terms of treatment for this disease. Outside of the traditional surgery, can you talk about some of those advancements in some of the treatment options that are now available to patients?

Dr. Gabriel: Absolutely. Once again, going back to surgery, yes, surgery has been around for a long time. As a matter of fact, the first carotid procedure was done dating back to 1953 by Dr. Michael DeBakey. From there, we tweaked the surgery itself, but the non-surgical options have really come a long way. And I'm alluding to carotid artery angioplasty and stenting. So carotid artery angioplasty and stenting is when you don't make a big incision, but you place a small filter wire, which is made out of metal inside the artery to actually expand the artery. And by expanding the artery, you're able to decrease the size of the blockage and increase the space so that blood travels a lot easier. There have been tremendous headway and new technologies associated with that, which gives us a lot of excitement in the future because we do know that there are some patients who cannot have surgery. They're not great candidates for major surgery. So having an option, which is less invasive, is really exciting, and another thing that we can offer to these patients to really improve their treatment options.

Host: So just before we close here today, there's one thing that I always like to ask, given the fact that you've probably seen hundreds of patients with carotid stenosis, what's one thing that you know, to be true, that you just wish more people knew before they came to see you?

Dr. Gabriel: I think the most important thing is preventive medical management is so key. Unfortunately, by the time they reach us, as we alluded to at the beginning of our discussion, the heart can be affected. The kidneys can be affected. The neck can be affected. Yes, we're only treating that neck at the time that they're seeing me. But since it's such a constellation of symptoms that could affect everything, prevention is so important, meaning following a good diet, taking your appropriate medications, having appropriate follow-up, even doing an exercise regimen or really focusing on [not] smoking is so key in terms of not only helping what happens to you with your neck arteries, but also your heart, your kidneys, your legs, and everything else. I think that's the most important thing. We're just catching them at the end with their neck, but yes, everything gets transferred to everything else throughout the body, which is so important to understand.

Host: That totally makes sense to me, Dr. Gabriel. Well this has been a fascinating conversation. I really appreciate your time. Is there anything else you'd like to leave our audience with?

Dr. Gabriel: I think they have a good understanding of everything and I want to wish them the best in terms of achieving health and happiness.

Host: Awesome. Well, thanks so much for joining us today, Dr. Gabriel.

Dr. Gabriel: Thank you.

Host: And that wraps up this episode of BayCare HealthChat. To learn more about heart and vascular services offered at BayCare, you can visit BayCareHeart.org. Please remember to subscribe, rate, and review this podcast and all other BayCare podcasts. For more health tips and updates, you can follow us on your social channels.

My name is Prakash Chandran. Thanks again for listening and we'll talk next time.