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It's a condition that's treatable if caught early. So we're discussing carotid artery disease. Our guest, Dr. Ahmed Khalil. He's Chief of Vascular Surgery for Jamaica Hospital Medical Center. This is Jamaica Hospital Med Talk. Thanks for joining us. I'm Joey Wahler. Hi, Dr. Khalil. Welcome.

Ahmed Khalil, MD: Hi, Joey. 

Host: Great to have you aboard. So first in a nutshell, so we're clear, what exactly is carotid artery disease, which has different levels, right?

Ahmed Khalil, MD: Yes. Basically, the carotid arteries are the main pipes that supply blood flow to the brain. There is one on the right and one on the left. Any disease that affects these pipes would interfere with the blood flow to the brain.

Host: And obviously interfering with blood flow to the brain is something no one wants to have to face, right?

Ahmed Khalil, MD: Of course. So what occurs from a carotid artery disease, it just takes only a few minutes for a part of the brain to be deprived of blood flow. That part of the brain would die.

Host: Gotcha. So what are the symptoms and problems associated with this disease?

Ahmed Khalil, MD: So, if a part of the brain dies, we call it a stroke. And a stroke can result in inability to move a part of the body, inability to speak, inability to see, inability to sense. These buses can be sensory or it can be involving the motor function and basically it can cause paralysis. 

Host: So, what are the factors in one's life that can increase the likelihood of developing this disease?

Ahmed Khalil, MD: Well, the risk factors for carotid artery disease are mainly the risk factors for atherosclerosis, like smoking, high cholesterol, patients with genetic predisposition, age and diabetes.

Host: So this is something that can be hereditary in some cases. 

Ahmed Khalil, MD: It can be genetics. Genetic factors play an important role. However, we cannot control genetics. We cannot control aging, but we can control smoking. We can control what we eat. We can control cholesterol. We can exercise, which would lower our risk. We can control our blood sugar levels if we have diabetes. And if we are in a high risk group, we can start screening or checking out if we do have before the problem happens.

Host: And so speaking of which, what are some of the signs that this disease could be present? 

Ahmed Khalil, MD: Generally speaking, the carotid artery disease or a disease of these pipes; the most common disease is atherosclerosis, meaning hardening of the pipe wall and thickening that happens gradually and end up in clogging up that artery. This is not a mere, blood clot that blocks it.

No, it's, a material that is built from cement like, cholesterol deposition. It becomes called the plaque. These plaques starts disintegrating and sometimes parts of them break loose and go down the line and block a part of the brain. And that's the problem that we have from this.

So if we are going to talk about the symptoms, we can categorize the carotid artery disease into two categories. Asymptomatic or symptomatic. Asymptomatic are the patients who were discovered before developing the actual problem. These are patients who have a blockage, but it did not reach a point to damage part of the brain yet.

And they're usually incidentally discovered when being worked up for another reason or in a screening process. Now, the other group of the patients are the symptomatic patients, which have had an event already that had resulted from that carotid blockage, which is a stroke or what we call a mini stroke.

A stroke is a loss of function of a part of the body, like inability to move, inability to feel, inability to see or talk for more than 24 hours. When it's less than 24 hours, we call it TIA or mini stroke, but it's basically the same. 

Host: And so at what point should carotid artery disease be treated? It sounds as though it needs to be addressed the sooner the better.

Ahmed Khalil, MD: It's based on these two categories. Since we divided the patients into asymptomatic group and symptomatic group; the asymptomatic patients, the recommendations are treat the blockage when it's more than 70 percent of that artery. For patients who have developed symptoms, i. e. mini stroke or a full blown stroke, these patients are likely to have more strokes down the line and more significant ones. So the treatment recommendation in this group is when it's 50 percent or more.

Host: Because, correct me if I'm wrong doctor, but once one suffers an initial stroke, you're then more likely to have another than someone that's not had one, right? 

Ahmed Khalil, MD: Yeah. So if you think about this is an unstable plaque, or a piece of rock inside the pipe, and parts of it are starting to break loose. So you're getting an initial event, but that is likely that down the line, a bigger part is going to break loose. We have found up to 26 percent, within the same year, a major stroke happening after patients start developing symptoms from a carotid blockage that is more than 50 percent.

Host: Gotcha. Now you mentioned screening. Are there any signs that a patient could notice that might indicate the presence of this? And what are the recommendations regarding screening both for the average person and those that are more predisposed as you touched on earlier?

Ahmed Khalil, MD: So the symptoms again, unfortunately, are either a mini stroke, which is a partial paralysis or a paralysis that happens for less than 24 hours or a full stroke that leaves a residual. So you don't have symptoms until this happens. However, if you're lucky to identify before the symptoms, that is our goal.

Patients that are up for screening are patients who have atherosclerosis in the heart, patients who have a family history of strokes, patients who are smokers, patients who are generally high risk category.

Host: And so you've clarified then that short of something like a mini stroke and what you just laid out there, there really is nothing less serious, if you will, that someone might notice. And so what do you recommend in terms of screening as far as frequency and when and age, et cetera?

Ahmed Khalil, MD: Usually it's if you have a risk factor in the family, so the parent have developed it, usually the screening starts 10 years before the age of the parent have developed the stroke. Like a father have developed a stroke at 50, you start at 40. You do an ultrasound.

Patients who has aneurysms, they're high risk for having a carotid artery disease should be screened. Patients who have severe heart disease and disease atherosclerosis, hardening of the walls in the heart and hardening of the walls of the pipes in the legs, they're likely to have it also. So they also should have a screening.

Host: And what does that screening actually consist of?

Ahmed Khalil, MD: It's an ultrasound, taking pictures with the ultrasound and measuring the narrowing based on the velocity of the blood flow in the pipe. So the ultrasound it's not as specific as a CAT scan or a picture that you are taking, it gives you a picture, but it's depending on the blood velocity.

The flow velocity of the blood gives you the indication of how much that pipe has narrowed. So the faster the blood is flowing, that means that the blood vessel has narrowed down. And we measure the velocity of the blood with the ultrasound. But it's using the ultrasound, which is a non invasive test.

Host: Gotcha. Switching gears a little bit, doc, how about treatment options for carotid artery disease?

Ahmed Khalil, MD: Everything is based on the degree of the narrowing and the symptoms. So, patients who are asymptomatic and have more than 70 percent narrowing, they are indicated for treatment. Patients who are symptomatic and have more than 50 percent narrowing are also indicated for treatment. The treatment falls into three categories, medical management, endovascular or minimally invasive management or open surgical management. 

Host: And so, what would you say are the complications associated with those procedures?

Ahmed Khalil, MD: Let me just tell you first, who gets what. So, generally speaking, if there is an indication based on the symptoms and the degree of the narrowing, we start by first thing, if the patient's general condition, does the patient's general condition tolerate to have an operation, an open surgery?

If the patient's general condition tolerates an open surgery, generally the open surgery, it's called a carotid endarterectomy is the recommended first option. Some of the risks of the surgery itself include having stroke during the operation. However, the risk of having stroke during operation between two to 3 percent as comparing to 26 to up to 30 percent of doing nothing within the year, that you develop a bigger stroke.

There are other risks of having some nerve injuries, but all these risks are less than 5%. So 95 percent in an experienced center, you have minimal chances of having a complication. The next option, for patients that their general condition does not allow an open surgery, would be placing a stent.

A stent is placed by two types of approaches. One of them is through the groin and goes all the way to the neck. And the other one is through a small, cut in the neck. And we place a stent through that. And then the third option is just to do nothing. If somebody's condition it's not good and it does not allow them to undergo either of these procedures.

Or if someone has had, uh, a severe stroke that that part of the brain is completely dead, then there is nothing else to prevent. Then at that point, the medical management would be recommended, which is just giving dual antiplatelets, it's blood thinners. Two antiplatelet medications and control cholesterol and observe.

Host: Understood. A few other things before we let you go. First, what are the dangers of carotid artery disease going untreated?

Ahmed Khalil, MD: Patients who have started to show symptoms, they are at a higher risk of developing stroke within the year. There's a big study called the NASCET where we have compared patients who have done the surgery and patients who have not done the surgery and had only medical treatment and have found that within the year, the chances are 26 percent that person will develop a stroke and a big stroke within the year if left untreated as compared, to if treated.

Host: Okay, well, I think those numbers certainly speak for themselves. In summary here, Doctor, how can patients make an appointment with a vascular surgeon like yourself at JHMC?

Ahmed Khalil, MD: You can have our information on our website, for the Department of Surgery Division of Vascular Surgery. And, you can have our number also. We can be reached by phone. It's 718-206-7110 and 718-206-6715.

Host: All right. And folks, we trust you're now more familiar with carotid artery disease. Dr. Ahmed Khalil, valuable information, perhaps life saving information. Keep up the great work and thanks so much again.

Ahmed Khalil, MD: Thank you very much, Joey. It's a pleasure to talk to you.

Host: Same here. And for more information about the services that Jamaica Hospital offers, please visit jamaicahospital.org/podcasts. If you found this one helpful, please do share it on your social media. I'm Joey Wahler, and thanks again for being part of Jamaica Hospital Med Talk.