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Diagnosing Carotid Artery Stenosis and Early Intervention
Dr. Mujtaba Ali discusses diagnosing Carotid Artery Stenosis and early intervention techniques.
Featured Speaker:
Mujtaba Ali, MD
Mujtaba Ali, MD is a Vascular Surgeon on the medical staff at Baylor Scott & White Heart and Vascular Hospital - Fort Worth and Baylor Scott & White All Saints Medical Center in Fort Worth. Transcription:
Diagnosing Carotid Artery Stenosis and Early Intervention
Prakash Chandran (Host): Hello and welcome to HeartSpeak with Baylor Scott and White Heart and Vascular Hospital in Dallas and in Fort Worth. I’m your host Prakash Chandran.
Joining us today on HeartSpeak is Vascular Surgeon Mujtaba Ali, who is on the Medical Staff at Baylor Scott and White Heart and Vascular Hospital Fort Worth. New to the area, Dr. Ali brings the Latest in innovative approaches to vascular surgery to Tarrant County. Dr. Ali performed a first at the hospital, the first TCAR procedure in Fort Worth. TCAR stands for trans carotid artery revascularization. This procedure is performed on patients with carotid artery stenosis. There are only a small group of vascular surgeons around the country that are performing this procedure that can help patients avoid debilitating stroke. So, Dr. Ali, it’s great to have you here today. I’d love to start by helping our listeners understand what carotid artery stenosis actually is.
Mujtaba Ali, MD (Guest): So, let me first begin with saying that carotid artery stenosis is a build up of cholesterol plaque in the carotid artery. And this leads to, if untreated, complications of a stroke. Carotid arteries are the arteries that supply the brain with blood. And they arise from the aorta which is close to the heart and then bring the blood up through the neck and then empty out into the brain.
So, the carotid stenosis if it happens, which is plaque build up within these arteries; it can potentially lead to a stroke which can be a very debilitating and oftentimes can be a fatal event also.
Host: Got it. So, the carotid arteries are the arteries that supply blood to the brain. I’m curious as to if the carotid artery stenosis is a common condition.
Dr. Ali: Yeah, it is fairly common. Much like coronary artery disease which is a build up of cholesterol plaque within the arteries of the heart. Similarly, cholesterol plaque can build up in the carotid arteries of the neck. And people have done studies on this and the prevalence rate for those among age 70; is higher than those less than age 70. So, for example in men, there’s about 12 to 13% prevalence of carotid artery stenosis after the age of 70. And in women, it’s around 7%. Altogether, the pooled prevalence of moderate disease or moderate blockage is around 4% in people in the United States in this country. So, it is a somewhat common, not as common as heart disease, but it is common, and it is the leading cause of an ischemic stroke which is blockages causing stroke. So, it is a fairly common condition and left untreated; it can cause a stroke.
Host: Yeah, speaking of plaque buildup, I’m really curious as to how plaque builds up in the first place and what happens to people when they have plaque?
Dr. Ali: So, plaque buildup happens where there’s chemical injury to the lining of the artery on the inside. And this can be due to history of smoking, from the nicotine in the cigarette smoke, that can injure the artery on the inside, or it could be from high blood sugars resulting in diabetes or high blood pressure or having high cholesterol. All these conditions predispose a person to developing blockages in the carotid artery and also elsewhere in the heart and the legs. And once plaque starts building up; there is potential for the plaque rupturing and releasing blood clots within them – travel up to brain and cause a stroke. Or blood clots can form on the plaque itself and then get released up to the brain, cause a stroke. So, overall, plaque buildup is a bad thing no matter which artery it occurs in, but it becomes especially bad when it’s in the heart, can cause a heart attack or it happens in the neck, it can cause a stroke.
Host: So, I’m curious as to if your plaque is building up or if this is about to happen, are there any symptoms that people might experience before the stroke itself?
Dr. Ali: Yeah so fortunately, not everyone gets a major stroke as a result of carotid artery stenosis. People can have TIAs which are transient ischemic attacks or in simpler terms called minor strokes and these are strokes that happen, but the symptoms don’t last for more than a day. Patients can have stroke like symptoms, but they resolve fairly quickly. The other symptom that can happen is transient blindness of the eye on the side of the blockage in the carotid artery. Essentially this is having like a mini stroke of the eye. The carotid artery not only supplies the brain but also supplies blood to the eye. So when the blood clots travel up into the artery that supplies the eye; that can lead to transient blindness for a few minutes. This is called amaurosis fugax. So, when patients have amaurosis fugax or TIAs; that’s a sign that a stroke might be right around the corner. People with TIAs have a 23% risk for having a major stroke within a year of having a TIA.
So, it’s essentially a warning sign for having a major stroke. Since there’s a one out of four chance of having a major stroke. So, when we see patients with amaurosis fugax or TIA, we also recommend that they undergo carotid artery surgery in order to remove the plaque.
Host: So, before the surgery itself, how is this carotid disease managed? Is it possible to be medically managed?
Dr. Ali: First and foremost, we advocate for medical management with blood thinning medications such as aspirin and or Plavix and a newer class of medications which is Xarelto. Additionally, cholesterol lowering medications are very, very helpful and are essential to stabilizing the plaque and perhaps in some cases; making the plaque regress too. Additionally, lowering the blood pressure, managing blood sugars, keeping them in optimal levels, is also very essential. And lastly, but not least; cutting back on smoking and all together quitting smoking is of great help in preventing further stroke and other complications of carotid artery stenosis.
So, that’s the first and foremost. But what studies have shown that in addition to medical management; surgery is also beneficial in those having symptoms and having a degree of stenosis which is 70% or more. In other words, if someone has a blockage of 70% or more; and has had transient blindness in the eye or a mini stroke or a major stroke; surgery has been shown to be more beneficial than just medical management.
Medical management is also essential regardless of the patient undergoing surgery or not. But when the threshold of disease is more than 70% blockage; then studies have shown that surgery is definitely more beneficial than just medical management.
Host: And can you actually speak to how you go about measuring the blockage itself?
Dr. Ali: Most commonly, we get an ultrasound. It’s called a duplex ultrasound. We take a look at the degree of blockage by calculating how fast the blood is flowing across the blockage and also looking in the blockage itself. So, that’s one type of test. The other two types of tests that are commonly done are a CAT scan and an MRI scan. So, these are specific scans that look at the arteries and they are called CT Angiogram or MR Angiogram and finally, if a patient does have a stroke, we also get an MRI of the brain to confirm that patient has had a stroke or not.
But the carotid artery stenosis is typically diagnosed initially with an ultrasound and for confirmatory tests, we order a CT Angiogram or an MR Angiogram.
Host: Okay. So, I want to transition to when surgery is needed. What is the most conventional surgery that happens and then talk a little bit about this TCAR procedure.
Dr. Ali: Definitely. So, the conventional operation is called carotid endarterectomy and it’s a invasive operation that involves making a long incision on the side of the neck and directly taking the plaque out. The other operation, the TCAR operation; this is performed under local anesthesia without any need for general anesthesia. A small incision is made just above the collar bone, instead of making a long incision. So through the small incision, we are able to expose the carotid artery and then a soft flexible tube is placed directly into the carotid artery and it’s connected to a specialized system to reverse blood flow in the carotid artery. So, blood flow is temporarily reversed to protect the brain against any fragments of plaque that might come loose during the procedure. The blood is filtered and then returned back to the body through another tube that’s placed into the femoral vein in the thigh.
While the blood flow is reversed; in about five or six minutes timeframe; we are able to insert a stent and then open up the blockage within the carotid artery. That’s why this is called a trans-carotid artery revascularization. We do it through the carotid artery and insert a stent. Now it’s a less invasive procedure as I was talking to you about compared to carotid endarterectomy. So, studies have now shown that this has less stroke risk during the procedure compared to carotid endarterectomy. This actually decreases the stroke risk of the conventional operation carotid endarterectomy.
To give you absolute numbers; stroke risk for TCAR procedure is around 1% and for carotid endarterectomy, it’s about 2-3%. But definitely, it’s a big leap in technology and an advance in medical care and the FDA approved this in the year 2015. I am one of the first ones to do it in Tarrant County and I’m glad that we have the service available for Tarrant County residents. But it’s important that a vascular surgeon does this procedure. And a vascular surgeon who has been trained by the FDA to do this procedure. So, not every vascular surgeon is doing this procedure. So, I’m fortunate that I got the training done.
Host: It’s truly amazing to hear about how far the medicine has come here and just a small incision that you are able to make, you are able to reverse the blood flow, effectively filter out and make sure that the plaque doesn’t affect the brain and then place a stent so the patient doesn’t have a problem anymore and I imagine that the recovery time is relatively quick because the incision is so small. Is that correct?
Dr. Ali: Yeah, the incision is approximately three centimeters, about an inch long, slightly over an inch long. And patients do very well in the operating room under a little bit of local anesthesia and I talk to them during the operation. We play music while they relax, and I get the procedure done and then they are in the ICU for one night. And in the ICU, they have very little fluctuations in blood pressure for the most part. The stent, after it’s placed, continues to expand and open the blockage little by little. So, we have to monitor the patients in the ICU. But what we notice that most patients actually do real well, have less degree of fluctuations compared to patients who have undergone carotid endarterectomy. So, overall, even the recovery process is a lot gentler. Patients recover faster and they go home the next day which is a remarkable thing.
Carotid endarterectomy, they also go home usually the next day, but sometimes they have to stay an additional night. I have yet to keep a patient more than one night after the TCAR procedures. So, it’s truly a very good procedure and the patients are safer undergoing this procedure compared to carotid endarterectomy and as the technology continues to expand; this procedure might become totally percutaneous, maybe fifteen years down the road. So, even what we have right now is quite remarkable and I look forward to with the improvements in technology doing this even percutaneously even latter down the road.
Host: Absolutely. Well Dr. Ali, I really appreciate your time and insight today. That’s Dr. Mujtaba Ali, a Vascular Surgeon at Baylor Scott and White Heart and Vascular Hospital in Fort Worth. Thanks for checking out this episode of HeartSpeak. To find a specialist on the medical staff at Baylor Scott and White Heart and Vascular Hospital in Fort Worth or Dallas; please call 844-279-3627 or visit www.baylorehearthospital.com. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks and we’ll talk next time.
Diagnosing Carotid Artery Stenosis and Early Intervention
Prakash Chandran (Host): Hello and welcome to HeartSpeak with Baylor Scott and White Heart and Vascular Hospital in Dallas and in Fort Worth. I’m your host Prakash Chandran.
Joining us today on HeartSpeak is Vascular Surgeon Mujtaba Ali, who is on the Medical Staff at Baylor Scott and White Heart and Vascular Hospital Fort Worth. New to the area, Dr. Ali brings the Latest in innovative approaches to vascular surgery to Tarrant County. Dr. Ali performed a first at the hospital, the first TCAR procedure in Fort Worth. TCAR stands for trans carotid artery revascularization. This procedure is performed on patients with carotid artery stenosis. There are only a small group of vascular surgeons around the country that are performing this procedure that can help patients avoid debilitating stroke. So, Dr. Ali, it’s great to have you here today. I’d love to start by helping our listeners understand what carotid artery stenosis actually is.
Mujtaba Ali, MD (Guest): So, let me first begin with saying that carotid artery stenosis is a build up of cholesterol plaque in the carotid artery. And this leads to, if untreated, complications of a stroke. Carotid arteries are the arteries that supply the brain with blood. And they arise from the aorta which is close to the heart and then bring the blood up through the neck and then empty out into the brain.
So, the carotid stenosis if it happens, which is plaque build up within these arteries; it can potentially lead to a stroke which can be a very debilitating and oftentimes can be a fatal event also.
Host: Got it. So, the carotid arteries are the arteries that supply blood to the brain. I’m curious as to if the carotid artery stenosis is a common condition.
Dr. Ali: Yeah, it is fairly common. Much like coronary artery disease which is a build up of cholesterol plaque within the arteries of the heart. Similarly, cholesterol plaque can build up in the carotid arteries of the neck. And people have done studies on this and the prevalence rate for those among age 70; is higher than those less than age 70. So, for example in men, there’s about 12 to 13% prevalence of carotid artery stenosis after the age of 70. And in women, it’s around 7%. Altogether, the pooled prevalence of moderate disease or moderate blockage is around 4% in people in the United States in this country. So, it is a somewhat common, not as common as heart disease, but it is common, and it is the leading cause of an ischemic stroke which is blockages causing stroke. So, it is a fairly common condition and left untreated; it can cause a stroke.
Host: Yeah, speaking of plaque buildup, I’m really curious as to how plaque builds up in the first place and what happens to people when they have plaque?
Dr. Ali: So, plaque buildup happens where there’s chemical injury to the lining of the artery on the inside. And this can be due to history of smoking, from the nicotine in the cigarette smoke, that can injure the artery on the inside, or it could be from high blood sugars resulting in diabetes or high blood pressure or having high cholesterol. All these conditions predispose a person to developing blockages in the carotid artery and also elsewhere in the heart and the legs. And once plaque starts building up; there is potential for the plaque rupturing and releasing blood clots within them – travel up to brain and cause a stroke. Or blood clots can form on the plaque itself and then get released up to the brain, cause a stroke. So, overall, plaque buildup is a bad thing no matter which artery it occurs in, but it becomes especially bad when it’s in the heart, can cause a heart attack or it happens in the neck, it can cause a stroke.
Host: So, I’m curious as to if your plaque is building up or if this is about to happen, are there any symptoms that people might experience before the stroke itself?
Dr. Ali: Yeah so fortunately, not everyone gets a major stroke as a result of carotid artery stenosis. People can have TIAs which are transient ischemic attacks or in simpler terms called minor strokes and these are strokes that happen, but the symptoms don’t last for more than a day. Patients can have stroke like symptoms, but they resolve fairly quickly. The other symptom that can happen is transient blindness of the eye on the side of the blockage in the carotid artery. Essentially this is having like a mini stroke of the eye. The carotid artery not only supplies the brain but also supplies blood to the eye. So when the blood clots travel up into the artery that supplies the eye; that can lead to transient blindness for a few minutes. This is called amaurosis fugax. So, when patients have amaurosis fugax or TIAs; that’s a sign that a stroke might be right around the corner. People with TIAs have a 23% risk for having a major stroke within a year of having a TIA.
So, it’s essentially a warning sign for having a major stroke. Since there’s a one out of four chance of having a major stroke. So, when we see patients with amaurosis fugax or TIA, we also recommend that they undergo carotid artery surgery in order to remove the plaque.
Host: So, before the surgery itself, how is this carotid disease managed? Is it possible to be medically managed?
Dr. Ali: First and foremost, we advocate for medical management with blood thinning medications such as aspirin and or Plavix and a newer class of medications which is Xarelto. Additionally, cholesterol lowering medications are very, very helpful and are essential to stabilizing the plaque and perhaps in some cases; making the plaque regress too. Additionally, lowering the blood pressure, managing blood sugars, keeping them in optimal levels, is also very essential. And lastly, but not least; cutting back on smoking and all together quitting smoking is of great help in preventing further stroke and other complications of carotid artery stenosis.
So, that’s the first and foremost. But what studies have shown that in addition to medical management; surgery is also beneficial in those having symptoms and having a degree of stenosis which is 70% or more. In other words, if someone has a blockage of 70% or more; and has had transient blindness in the eye or a mini stroke or a major stroke; surgery has been shown to be more beneficial than just medical management.
Medical management is also essential regardless of the patient undergoing surgery or not. But when the threshold of disease is more than 70% blockage; then studies have shown that surgery is definitely more beneficial than just medical management.
Host: And can you actually speak to how you go about measuring the blockage itself?
Dr. Ali: Most commonly, we get an ultrasound. It’s called a duplex ultrasound. We take a look at the degree of blockage by calculating how fast the blood is flowing across the blockage and also looking in the blockage itself. So, that’s one type of test. The other two types of tests that are commonly done are a CAT scan and an MRI scan. So, these are specific scans that look at the arteries and they are called CT Angiogram or MR Angiogram and finally, if a patient does have a stroke, we also get an MRI of the brain to confirm that patient has had a stroke or not.
But the carotid artery stenosis is typically diagnosed initially with an ultrasound and for confirmatory tests, we order a CT Angiogram or an MR Angiogram.
Host: Okay. So, I want to transition to when surgery is needed. What is the most conventional surgery that happens and then talk a little bit about this TCAR procedure.
Dr. Ali: Definitely. So, the conventional operation is called carotid endarterectomy and it’s a invasive operation that involves making a long incision on the side of the neck and directly taking the plaque out. The other operation, the TCAR operation; this is performed under local anesthesia without any need for general anesthesia. A small incision is made just above the collar bone, instead of making a long incision. So through the small incision, we are able to expose the carotid artery and then a soft flexible tube is placed directly into the carotid artery and it’s connected to a specialized system to reverse blood flow in the carotid artery. So, blood flow is temporarily reversed to protect the brain against any fragments of plaque that might come loose during the procedure. The blood is filtered and then returned back to the body through another tube that’s placed into the femoral vein in the thigh.
While the blood flow is reversed; in about five or six minutes timeframe; we are able to insert a stent and then open up the blockage within the carotid artery. That’s why this is called a trans-carotid artery revascularization. We do it through the carotid artery and insert a stent. Now it’s a less invasive procedure as I was talking to you about compared to carotid endarterectomy. So, studies have now shown that this has less stroke risk during the procedure compared to carotid endarterectomy. This actually decreases the stroke risk of the conventional operation carotid endarterectomy.
To give you absolute numbers; stroke risk for TCAR procedure is around 1% and for carotid endarterectomy, it’s about 2-3%. But definitely, it’s a big leap in technology and an advance in medical care and the FDA approved this in the year 2015. I am one of the first ones to do it in Tarrant County and I’m glad that we have the service available for Tarrant County residents. But it’s important that a vascular surgeon does this procedure. And a vascular surgeon who has been trained by the FDA to do this procedure. So, not every vascular surgeon is doing this procedure. So, I’m fortunate that I got the training done.
Host: It’s truly amazing to hear about how far the medicine has come here and just a small incision that you are able to make, you are able to reverse the blood flow, effectively filter out and make sure that the plaque doesn’t affect the brain and then place a stent so the patient doesn’t have a problem anymore and I imagine that the recovery time is relatively quick because the incision is so small. Is that correct?
Dr. Ali: Yeah, the incision is approximately three centimeters, about an inch long, slightly over an inch long. And patients do very well in the operating room under a little bit of local anesthesia and I talk to them during the operation. We play music while they relax, and I get the procedure done and then they are in the ICU for one night. And in the ICU, they have very little fluctuations in blood pressure for the most part. The stent, after it’s placed, continues to expand and open the blockage little by little. So, we have to monitor the patients in the ICU. But what we notice that most patients actually do real well, have less degree of fluctuations compared to patients who have undergone carotid endarterectomy. So, overall, even the recovery process is a lot gentler. Patients recover faster and they go home the next day which is a remarkable thing.
Carotid endarterectomy, they also go home usually the next day, but sometimes they have to stay an additional night. I have yet to keep a patient more than one night after the TCAR procedures. So, it’s truly a very good procedure and the patients are safer undergoing this procedure compared to carotid endarterectomy and as the technology continues to expand; this procedure might become totally percutaneous, maybe fifteen years down the road. So, even what we have right now is quite remarkable and I look forward to with the improvements in technology doing this even percutaneously even latter down the road.
Host: Absolutely. Well Dr. Ali, I really appreciate your time and insight today. That’s Dr. Mujtaba Ali, a Vascular Surgeon at Baylor Scott and White Heart and Vascular Hospital in Fort Worth. Thanks for checking out this episode of HeartSpeak. To find a specialist on the medical staff at Baylor Scott and White Heart and Vascular Hospital in Fort Worth or Dallas; please call 844-279-3627 or visit www.baylorehearthospital.com. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks and we’ll talk next time.