Evo Terra (Host): Your risk of carotid artery disease increases as you get older. In fact, 3% of people over 65 have carotid artery disease. How can you mitigate your risk of developing the disease? Let's find out with Dr. Nathan Aronson, a dual board-certified vascular surgeon with the Vascular Care Group.

This is Answers in Vascular from the Vascular Care Group. I'm Evo Terra. Dr. Aronson, thanks for joining me today and helping us all understand carotid artery disease.

Dr. Nathan Aranson: Thank you very much for the invitation. Happy to be here.

Host: I have several questions for you, but can you start out by giving us a short overview of carotid artery disease and maybe tell us how it's diagnosed?

Dr. Nathan Aranson: Absolutely. So, the carotid arteries are paired arteries that exist in the front of the neck, bringing blood from the heart to the brain. They're a hotbed for the development of plaque or cholesterol and calcium buildup, which is more prevalent in people who smoke cigarettes, have high blood pressure, high cholesterol, or a genetic predisposition to this.

Obviously, when these arteries get narrowed or plugged up, some of the material, the plaque, can dislodge and go to the brain, leading to stroke. And obviously, stroke can be quite detrimental to people's lives and can lead to death. This is most commonly identified either due to concern based on people's alternate comorbidities, high blood pressure, high cholesterol, smoking, as I mentioned, and is most readily diagnosed with ultrasound, an easy and quick test that can be done in most vascular surgical offices, most hospitals, et cetera.

Host: Let's talk about stroke for a second. And I think you brought up this in your conversation, but I want to narrow it down. Who is at risk for stroke? And should everybody who has some level of risk of stroke go under surveillance imaging?

Dr. Nathan Aranson: I think stroke is one of the things that people as they age are most terrified of. Heart attack being among them, cancer as well. And stroke has a relatively increasing prevalence within the United States population. Not everyone who has had a stroke will have carotid artery disease, only one in four or one in five people who have suffered a stroke will have carotid artery disease. The overwhelming majority will have things such as brain bleeds from aneurysm, brain trauma with bleeding, cancer, et cetera. But one in four or one in five people who suffer a stroke will have that because of carotid artery disease, plaque buildup, narrowing.

Host: Okay, great. Let's say, for example, that I got an ultrasound on my carotid arteries. What is it telling me that I've got an ultrasound of these blood vessels in my neck?

Dr. Nathan Aranson: Yes. We often see patients who come in and they're quite worried, worried about the results of an ultrasound. And I would say the overwhelming majority of people who have an ultrasound of their carotid arteries have nothing to worry about. But it leaves it up to us as a vascular surgeon to really tease out the nuances, the degree of narrowing, and determine who would best benefit from either surgical intervention, medical management, or just kind of a pat on the back and say, "Don't worry about it, you're fine."

Certainly, we know that as the artery narrows, the risk increases. I always tell my patients, if you picture the arteries like a river, when the river is wide, the water is calm. Same goes for your arteries. And as the arteries narrow, that's when you get into the rapids or the churning water. In this case, blood, you can imagine a fast moving, swirling bloodstream can flick off plaque and thus cause a stroke. And that's when we really worry.

Host: Yeah, that kind of brings it home. I love that analogy of the rapids and I hadn't thought about ripping plaque off of walls. But yes, I'm glad you said that. I'm also terrified that you said that. But assuming we're not in the pat-on-the-back, just go about your business that day, assuming they need one of the two other interventions you mentioned, surgical or medication, let's start with the medication side. What is it and how does it work?

Dr. Nathan Aranson: Carotid artery disease mirrors other forms of atherosclerosis or plaque buildup in the body. And we liken it to coronary disease or heart disease. A lot of the patients who come in and they have narrowing of their coronary arteries or the arteries to their heart, we talk about medical optimization, medical management, control of comorbidities, whether that be diabetes or high blood pressure or things like that.

Choosing healthy lifestyle options. It doesn't mean you have to become a vegan or do something as extreme as that, but certainly quitting smoking, choosing a heart-healthy diet participating in some form of moderate level of activity. All of these things help with heart and blood vessel health. In addition, we talk about initiation of antiplatelet therapy, that's as simple as a baby aspirin a day, statin therapy, things like Lipitor, Zocor, Crestor, you name it. And then, certainly if people have diabetes or high blood pressure, we really focus on the control of that. And that really runs the gamut of the basics for medical optimization. And then, obviously, we talk with a certain subset of people about surgical options.

Host: Right. Right. Let's move to that. I mean, obviously, if medications do what medications do, I hope, says the guy who's on three of the things you mentioned. But in the event that I continue to age, which I hope that I do and things change and I might need surgery, what am I looking at? Why might they need surgery and what are you going to do about it?

Dr. Nathan Aranson: In the United States, the overwhelming majority of people who have an intervention on their carotid artery are asymptomatic, so this is purely a prophylactic operation. This won't make you smarter, it won't make you do the New York Times Crossword faster, or learn a new language easier, but what it does is prevent you from having a stroke, or at least decrease your risk of developing a stroke. And that's probably about 85-90% of people who undergo a carotid intervention. For the smaller subset, 10-15%, those are people who come in because they have symptoms. Maybe they lost vision for a short term in an eye. Maybe they had a clumsy hand that came and went. And then, some people who have had a stroke, which is permanent death of the brain cells that won't return.

And for those patients, we talk about surgical intervention. And we talk about basically decreasing the risk of them having a stroke. And there are really three forms and flavors to that. The most tried, true, trusted, and well tested is carotid endarterectomy. That's an open surgical procedure performed through a small incision in the front of the neck. And that is done within the hospital where the plaque is actually removed from the artery and the artery is repaired to restore blood flow to the brain.

Another option is placing a stent into the artery. Sometimes that is done through going through the artery in the wrist or the artery in the groin, navigating catheters and wires through the bloodstream to place a stent. And the third option is probably the newest of the three, and very well tested. And that's a hybrid procedure of both. So, it involves a small surgical incision above the neck and placement of a stent directly into the artery. And that's called TCAR or transcarotid artery revascularization.

Host: Interesting. So, we have many options available to us right now. And I know that last one you mentioned is the newest one. Are there additional things being tested? What are you excited to about on the horizon, I guess, when it comes to more of a surgical intervention?

Dr. Nathan Aranson: I think the biggest thing that is pending right now is a multi-centered randomized trial looking at best medical therapy or medical optimization versus surgical intervention. And that's called the CREST trial, and this is in its second iteration. And when this comes out, it'll give us more information as to how well we are doing with purely medical optimization, or just medicines. We know that medicines alone will never reduce or remove the plaque burden, but the hope is that it stabilizes this plaque so it does not dislodge or flick off any of this debris to the brain. And potentially, this will lead to a decreased number of patients requiring an operation. But we won't know. We won't know for some time and we won't know how well that information will be processed and adopted by the surgical field at large.

Host: A to-be-continued, for sure. Taking a broad step back, we've been talking about carotid artery disease, and ways to prevent that and the issues that go with it. But this all is revolving around a stroke. That's really what we're trying to prevent here, is a stroke. Just in general, could you maybe wrap this with a conversation of what people should do who may be healthy right now to reduce the chance of them having a stroke?

Dr. Nathan Aranson: Absolutely. Good life choices. And the most deleterious and common one is cigarette smoking. And I think we know the ill effects of cigarette smoking or tobacco use. And I see patients all the time who are still smoking and I don't need to tell them why cigarette smoking is bad, but I tell them, you know, I'm on their side and I'm on their team and if they ever want to quit smoking and look at ways to do that, I'm happy to discuss that with them and support them, but that's probably the number one risk factor that we've seen in terms of development of carotid disease or carotid atherosclerosis and plaque that can lead to stroke. And that's quite modifiable. Obviously, even if you smoke for 40 or 50 years, today is as good of a day as I need to quit smoking.

Host: Yes. Yes, I will echo that. One thing I wanted clear up is the issue of when we should be tested. When should I be tested? What should I do if I'm worried or if I'm not worried? When is screening right for me? And of course, take me to mean whoever happens to be listening to this.

Dr. Nathan Aranson: Well, I'll start by saying that having a stroke is still a relatively rare phenomenon, although if you've had someone in your family or a loved one who's had a stroke, it's very damaging and devastating to their life and your life and relationship with them. It shouldn't lead to overwhelming worry and doom.

But for patients and people who have the appropriate risk factors, again, I'll talk about cigarette smoking, high blood pressure, high cholesterol, diabetes, maybe your family members have had stroke and heart attack at early ages, then certainly it makes sense to proceed to your primary care physician and see what they think and see if you could potentially have a quick and easy ultrasound ordered.

Alternatively, when you are seen by your primary care physician, a test as simple as putting a stethoscope onto the neck and listening for a whooshing sound called a bruit within the carotid artery can lead to early detection of carotid disease. And certainly earlier detection, even if it is 50% narrowed and not something that is going to require an operation even during your lifetime, you could visit with a vascular surgeon and they can provide you with really education on the matter and some comfort in that someone has a close eye on this.

Host: Excellent news. Dr. Aronson, thank you very much for joining me today.

Dr. Nathan Aranson: Absolutely. My pleasure. Thank you for having me.

Host: Once again, that was Dr. Nathan Aronson, a dual board-certified vascular surgeon with the Vascular Care Group. For more information, please visit thevascularcaregroup.com. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you.I'm Evo Terra, and this is Answers in Vascular from the Vascular Care Group. Thanks for listening.