Selected Podcast
State of the Art Management of Carotid Disease
Mark Harrigan MD and Elizabeth Liptrap MD discuss the array of management strategies at UAB Medicine for patients with carotid stenosis. They cover intensive medical management, surgery, stenting, a surgery/stenting hybrid technique, and the opportunity to participate in clinical trials.
Featuring:
Learn more about Mark Harrigan, MD
Elizabeth Liptrap, MD grew up in Maryland and received a B.S. degree in Biochemistry and Molecular Biology from the University of Maryland, Baltimore County (UMBC). She received an M.D. degree from the University of Maryland School of Medicine in 2011. During medical school, she was an Alpha Omega Alpha Carolyn L. Kuckein Student Research Fellow and received awards for excellence in Biological Chemistry, Surgery and Neurosurgery.
Learn more about Elizabeth Liptrap, MD
Release Date: November 30, 2020
Expiration Date: November 30, 2023
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Presenters:
Elizabeth Liptrap, MD
Assistant Professor, Brain and Tumor Neurosurgery,
Mark Harrigan, MD
Professor, Endovascular Neurosurgery,
Dr. Liptrap and Harrigan have no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity.
Mark Harrigan, MD | Elizabeth Liptrap, MD
Mark Harrigan, MD specializes in Endovascular Neurosurgery, Neurosurgery.Learn more about Mark Harrigan, MD
Elizabeth Liptrap, MD grew up in Maryland and received a B.S. degree in Biochemistry and Molecular Biology from the University of Maryland, Baltimore County (UMBC). She received an M.D. degree from the University of Maryland School of Medicine in 2011. During medical school, she was an Alpha Omega Alpha Carolyn L. Kuckein Student Research Fellow and received awards for excellence in Biological Chemistry, Surgery and Neurosurgery.
Learn more about Elizabeth Liptrap, MD
Release Date: November 30, 2020
Expiration Date: November 30, 2023
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Presenters:
Elizabeth Liptrap, MD
Assistant Professor, Brain and Tumor Neurosurgery,
Mark Harrigan, MD
Professor, Endovascular Neurosurgery,
Dr. Liptrap and Harrigan have no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity.
Transcription:
Melanie: Welcome to UAB MedCast. I'm Melanie Cole, and I invite you to listen in as we discuss state-of-the-art management of carotid disease.
Joining me in this panel are Dr. Elizabeth Liptrap, she's a neuroendovascular and vascular neurosurgeon and an assistant professor, and Dr. Mark Harrigan, he's an endovascular neurosurgeon and a professor of neurosurgery, and they're both with UAB medicine. Doctors, thank you so much for joining us again. It's always a pleasure.
Dr. Liptrap, let's start with you. Just tell us a little bit about carotid stenosis and really anything you'd like to kind of set the stage. The studies that are performed and the workup of atherosclerotic disease, the prevalence, anything you think is important.
Dr Liptrap: So atherosclerotic disease is a very common problem in the United States and especially for us here in Alabama. What we are focusing on today is carotid atherosclerotic disease. So that's when you have a buildup of cholesterol plaques within the carotid bulb. And so you've got two carotid arteries, one on either side, that bring blood flow to your head.
And so when you have carotid disease and plaque buildup in those blood vessels, you can be at risk of stroke. And the stroke can come either because the plaques caused so much narrowing that you're not getting enough blood flow to your head or because small pieces of the plaque can break off and go to the brain or, if the lesion erodes, you can form clots on that plaque, and those can also go to the brain and cause strokes.
Here at UAB, we're a comprehensive center for treating carotid disease. And we work in a multidisciplinary fashion with our stroke neurologists, interventionalists, neurosurgeons and vascular surgeons to treat carotid disease. When we have a patient that we're worried about that may have carotid stenosis, there are a variety of tests that you can do. Besides the blood work, looking at their cholesterol levels and things like that, you can do a carotid ultrasound to look at the flow within the carotid artery. A CT angiogram of the neck can also give you an idea of the degree of narrowing and the plaque that's there in the carotid. And if the patient has had a recent stroke or recent transient ischemic attack, we'll do an MRI to look and see what lesions they have in the brain as a result of that.
Melanie: So as you're telling us about the studies, Dr. Liptrap, are these mostly symptomatic patients? For other providers that are seeing patients, are they asymptomatic? Is it found incidentally? How would we know?
Dr Liptrap: So both. There are patients that have carotid disease that is found incidentally because they haven't had any symptoms. But I think a lot of the patients that we see here at UAB are symptomatic and they've had either a transient ischemic attack or a stroke. And those patients get this full workup with imaging and blood studies.
Melanie: So as we've just talked about the studies, Dr. Harrigan, speak about the array of management strategies that you provide patients with carotid stenosis. Tell us a little bit about pharmacologic, and then we can ease our way into some of the interventional strategies.
Dr Harrigan: Okay. There's been a paradigm shift in the management of carotid stenosis over the last 10 years or so, this new paradigm called aggressive or intensive medical management. And that means very tight control of risk factors for atherosclerosis, management of hyperlipidemia, for example, management of diabetes. We'd like to target, hemoglobin A1c level of less than 7 consistently across the board. We like to optimize blood pressure control. American Heart Association guidelines for blood pressure control changed a couple of years ago, and now they want us to keep people consistently below 130 millimeters of mercury systolic. And then usually an anti-platelet agent, like low-dose aspirin. So this has the mix of pharmacologic and medical management that we use with all patients with carotid stenosis, symptomatic or asymptomatic.
Dr Liptrap: I would also add smoking cessation as well.
Dr Harrigan: Absolutely important.
Melanie: Well then, now tell us about some of the interventions and the exciting ways that you're treating people with atherosclerosis of the carotid artery. Dr. Harrigan, tell us about some of the exciting things you're doing.
Dr Harrigan: We have the privilege of being able to offer our patients the full range of interventions for management of chronic stenosis. So that includes carotid endarterectomy and carotid stenting. And that there's a new way to treat carotid stenosis on the scene now, it's called TCAR, transcarotid arterial revascularization. Should we go through each kind of intervention? Should we start with surgery? Dr. Liptrap, do you want to talk about carotid endarterectomy?
Dr Liptrap: So when we are considering a patient for an intervention, these are usually patients that have exhausted the medical management strategies and lifestyle changes or have recently suffered from a stroke or transient ischemic attacks. And so for patients who have greater than 70% stenosis and have recently had a TIA or a stroke, those are patients that we would consider for a carotid endarterectomy or carotid stenting or TCAR, which dr. Harrigan will talk about. And patients who are asymptomatic can be considered for intervention if they have also exhausted medical management and have greater than 60% stenosis.
Regarding carotid endarterectomy, we have multiple surgeons here who perform this procedure. What happens is the patient goes under general anesthesia. There are some indications for patients to have the procedure under conscious sedation, but typically we do our carotid endarterectomies under general anesthesia. An incision would be made in the neck on the side of the carotid stenosis and then we go down to the carotid artery where the plaque is, open the artery, take out the plaque and sew in a patch to expand the diameter of the artery. The patient then has a drain for a day or two, and usually goes up to our ICU and is monitored there for one to two days.
Melanie: Dr. Harrigan, why don't you expand on all of this for us and tell us about TCAR?
Dr Harrigan: So we'll talk briefly about stenting next and then TCAR, because TCAR is really a hybrid between open surgery and stenting. So stenting of the carotid artery has emerged as a viable alternative to open surgery. It has several very attractive features to it in comparison to surgery. So we can do carotid stenting through a needlestick puncture in the femoral artery. It's minimally invasive. In that way, the patient doesn't have to go asleep for general anesthesia. And it's more convenient for the patient because they're not recovering from a surgery, but rather just a procedure.
Now, TCAR is the new thing on the scene and it's very popular across the country. TCAR involves a clever technique for protecting against embolization during the actual procedure. So with traditional transfemoral artery carotid stenting, what we'll do is position a filter device up above or distal to the area of stenosis during the angioplasty and placement of the stent, so if any debris is released from the plaque during the procedure, it's caught by the filter device.
TCAR in contrast employs actually reversing flow in the carotid artery during the angioplasty and placement of the stent. And so the way TCAR works is we make an incision above the clavicle. We expose the common carotid artery and then directly insert a sheath, a plastic sheath in the common carotid artery. And then we connect that sheath to a tube that drains into the femoral vein. And so while we go up with the balloon for the angioplasty, we literally reverse flow in the carotid system. The blood comes down in a retrograde fashion through the carotid system, through the sheath, through the tubing into the femoral vein. We can protect against embolization of debris from the plaque during the placement of the balloon and the stent in that manner.
Now, the results from the trials of TCAR are extremely favorable. They seem to be even better possibly than the traditional transfemoral approach using a filter. And it's possible that we found the magic bullet that the optimal way to protect against embolization of debris during carotid stenting may be this reversal of flow strategy. The results we've had at UAB had been very favorable. We do the procedure in neurosurgery and the vascular surgeons do it well, and we've had good results.
Melanie: Absolutely fascinating. And Dr. Harrigan, tell us about any opportunities to participate in clinical trials that you'd like other providers to know about.
Dr Harrigan: Absolutely. So we are enrolling patients in a major NIH sponsored trial of patients with asymptomatic carotid stenosis. So any patient with asymptomatic carotid stenosis of at least 70% can enroll. And it's a major effort. This is a huge undertaking by the NIH.
People that sign up for the trial, all subjects, are treated with this aggressive medical management paradigm with aggressive control of risk factors for atherosclerosis, as we talked about earlier. And then, patients can be randomly assigned to either having revascularization or not having revascularization. And we can use carotid surgery for patients in CREST-2. We can use carotid stenting in CREST-2. And we're about two thirds of the way through the trial on a national scale. We plan 2,400 subjects. Nationwide, we're about 1,800 subjects into it. We've had good results here at UAB. We've had about 16 subjects enrolled at UAB. They've had good results across the board, and we are actively looking for further subjects, recruitment. So if anybody has any patients with asymptomatic stenosis, please let us know.
Melanie: Dr. Liptrap, I want to give you each a chance as we wrap up for some final thoughts. Do you feel this development of some of these effective endovascular treatments for carotid stenosis has really revolutionized the management? As you're telling us about game-changers, I'd like you to reiterate when you feel it's important to refer to the specialists at UAB Medicine.
Dr Liptrap: So we're happy to see any patients that you may have with a carotid disease. And regarding the new techniques and current techniques that we have, it certainly gives greater options and safer options for patients with this disease. Patients with carotid stenosis who have had a stroke are at continued risk of stroke if it's not treated. And so for patients who cannot undergo a carotid endarterectomy for whatever reason and need to have carotid stenting, TCAR as Dr. Harrigan mentioned has really revolutionized that treatment, because a big issue with carotid stenting obviously is having the emboli break off during the procedure. And having new ways to treat patients that are safer and prevent any complications, obviously, that's always a good thing.
Melanie: And Dr. Harrigan, last word to you. As we're talking about the surgically and medically managed patients with carotid artery disease, what would you like other providers to take away from this episode? What do you feel are some of the most important points we've covered today?
Dr Harrigan: We view carotid stenosis management as a multidisciplinary process. So we in vascular neurosurgery here at UAB work very closely with the UAB Stroke Service in handling patients who have symptomatic disease as well as asymptomatic disease. So we take this multidisciplinary approach to carotid disease very seriously. And we take pride in being able to offer the full spectrum, including medical management to patients with chronic stenosis.
Melanie: Such an interesting topic. Doctors, thank you again for joining us. You are great guests as always. And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB MedCast to refer your patient or for more information on resources available at UAB Medicine, please visit our website at uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.
Melanie: Welcome to UAB MedCast. I'm Melanie Cole, and I invite you to listen in as we discuss state-of-the-art management of carotid disease.
Joining me in this panel are Dr. Elizabeth Liptrap, she's a neuroendovascular and vascular neurosurgeon and an assistant professor, and Dr. Mark Harrigan, he's an endovascular neurosurgeon and a professor of neurosurgery, and they're both with UAB medicine. Doctors, thank you so much for joining us again. It's always a pleasure.
Dr. Liptrap, let's start with you. Just tell us a little bit about carotid stenosis and really anything you'd like to kind of set the stage. The studies that are performed and the workup of atherosclerotic disease, the prevalence, anything you think is important.
Dr Liptrap: So atherosclerotic disease is a very common problem in the United States and especially for us here in Alabama. What we are focusing on today is carotid atherosclerotic disease. So that's when you have a buildup of cholesterol plaques within the carotid bulb. And so you've got two carotid arteries, one on either side, that bring blood flow to your head.
And so when you have carotid disease and plaque buildup in those blood vessels, you can be at risk of stroke. And the stroke can come either because the plaques caused so much narrowing that you're not getting enough blood flow to your head or because small pieces of the plaque can break off and go to the brain or, if the lesion erodes, you can form clots on that plaque, and those can also go to the brain and cause strokes.
Here at UAB, we're a comprehensive center for treating carotid disease. And we work in a multidisciplinary fashion with our stroke neurologists, interventionalists, neurosurgeons and vascular surgeons to treat carotid disease. When we have a patient that we're worried about that may have carotid stenosis, there are a variety of tests that you can do. Besides the blood work, looking at their cholesterol levels and things like that, you can do a carotid ultrasound to look at the flow within the carotid artery. A CT angiogram of the neck can also give you an idea of the degree of narrowing and the plaque that's there in the carotid. And if the patient has had a recent stroke or recent transient ischemic attack, we'll do an MRI to look and see what lesions they have in the brain as a result of that.
Melanie: So as you're telling us about the studies, Dr. Liptrap, are these mostly symptomatic patients? For other providers that are seeing patients, are they asymptomatic? Is it found incidentally? How would we know?
Dr Liptrap: So both. There are patients that have carotid disease that is found incidentally because they haven't had any symptoms. But I think a lot of the patients that we see here at UAB are symptomatic and they've had either a transient ischemic attack or a stroke. And those patients get this full workup with imaging and blood studies.
Melanie: So as we've just talked about the studies, Dr. Harrigan, speak about the array of management strategies that you provide patients with carotid stenosis. Tell us a little bit about pharmacologic, and then we can ease our way into some of the interventional strategies.
Dr Harrigan: Okay. There's been a paradigm shift in the management of carotid stenosis over the last 10 years or so, this new paradigm called aggressive or intensive medical management. And that means very tight control of risk factors for atherosclerosis, management of hyperlipidemia, for example, management of diabetes. We'd like to target, hemoglobin A1c level of less than 7 consistently across the board. We like to optimize blood pressure control. American Heart Association guidelines for blood pressure control changed a couple of years ago, and now they want us to keep people consistently below 130 millimeters of mercury systolic. And then usually an anti-platelet agent, like low-dose aspirin. So this has the mix of pharmacologic and medical management that we use with all patients with carotid stenosis, symptomatic or asymptomatic.
Dr Liptrap: I would also add smoking cessation as well.
Dr Harrigan: Absolutely important.
Melanie: Well then, now tell us about some of the interventions and the exciting ways that you're treating people with atherosclerosis of the carotid artery. Dr. Harrigan, tell us about some of the exciting things you're doing.
Dr Harrigan: We have the privilege of being able to offer our patients the full range of interventions for management of chronic stenosis. So that includes carotid endarterectomy and carotid stenting. And that there's a new way to treat carotid stenosis on the scene now, it's called TCAR, transcarotid arterial revascularization. Should we go through each kind of intervention? Should we start with surgery? Dr. Liptrap, do you want to talk about carotid endarterectomy?
Dr Liptrap: So when we are considering a patient for an intervention, these are usually patients that have exhausted the medical management strategies and lifestyle changes or have recently suffered from a stroke or transient ischemic attacks. And so for patients who have greater than 70% stenosis and have recently had a TIA or a stroke, those are patients that we would consider for a carotid endarterectomy or carotid stenting or TCAR, which dr. Harrigan will talk about. And patients who are asymptomatic can be considered for intervention if they have also exhausted medical management and have greater than 60% stenosis.
Regarding carotid endarterectomy, we have multiple surgeons here who perform this procedure. What happens is the patient goes under general anesthesia. There are some indications for patients to have the procedure under conscious sedation, but typically we do our carotid endarterectomies under general anesthesia. An incision would be made in the neck on the side of the carotid stenosis and then we go down to the carotid artery where the plaque is, open the artery, take out the plaque and sew in a patch to expand the diameter of the artery. The patient then has a drain for a day or two, and usually goes up to our ICU and is monitored there for one to two days.
Melanie: Dr. Harrigan, why don't you expand on all of this for us and tell us about TCAR?
Dr Harrigan: So we'll talk briefly about stenting next and then TCAR, because TCAR is really a hybrid between open surgery and stenting. So stenting of the carotid artery has emerged as a viable alternative to open surgery. It has several very attractive features to it in comparison to surgery. So we can do carotid stenting through a needlestick puncture in the femoral artery. It's minimally invasive. In that way, the patient doesn't have to go asleep for general anesthesia. And it's more convenient for the patient because they're not recovering from a surgery, but rather just a procedure.
Now, TCAR is the new thing on the scene and it's very popular across the country. TCAR involves a clever technique for protecting against embolization during the actual procedure. So with traditional transfemoral artery carotid stenting, what we'll do is position a filter device up above or distal to the area of stenosis during the angioplasty and placement of the stent, so if any debris is released from the plaque during the procedure, it's caught by the filter device.
TCAR in contrast employs actually reversing flow in the carotid artery during the angioplasty and placement of the stent. And so the way TCAR works is we make an incision above the clavicle. We expose the common carotid artery and then directly insert a sheath, a plastic sheath in the common carotid artery. And then we connect that sheath to a tube that drains into the femoral vein. And so while we go up with the balloon for the angioplasty, we literally reverse flow in the carotid system. The blood comes down in a retrograde fashion through the carotid system, through the sheath, through the tubing into the femoral vein. We can protect against embolization of debris from the plaque during the placement of the balloon and the stent in that manner.
Now, the results from the trials of TCAR are extremely favorable. They seem to be even better possibly than the traditional transfemoral approach using a filter. And it's possible that we found the magic bullet that the optimal way to protect against embolization of debris during carotid stenting may be this reversal of flow strategy. The results we've had at UAB had been very favorable. We do the procedure in neurosurgery and the vascular surgeons do it well, and we've had good results.
Melanie: Absolutely fascinating. And Dr. Harrigan, tell us about any opportunities to participate in clinical trials that you'd like other providers to know about.
Dr Harrigan: Absolutely. So we are enrolling patients in a major NIH sponsored trial of patients with asymptomatic carotid stenosis. So any patient with asymptomatic carotid stenosis of at least 70% can enroll. And it's a major effort. This is a huge undertaking by the NIH.
People that sign up for the trial, all subjects, are treated with this aggressive medical management paradigm with aggressive control of risk factors for atherosclerosis, as we talked about earlier. And then, patients can be randomly assigned to either having revascularization or not having revascularization. And we can use carotid surgery for patients in CREST-2. We can use carotid stenting in CREST-2. And we're about two thirds of the way through the trial on a national scale. We plan 2,400 subjects. Nationwide, we're about 1,800 subjects into it. We've had good results here at UAB. We've had about 16 subjects enrolled at UAB. They've had good results across the board, and we are actively looking for further subjects, recruitment. So if anybody has any patients with asymptomatic stenosis, please let us know.
Melanie: Dr. Liptrap, I want to give you each a chance as we wrap up for some final thoughts. Do you feel this development of some of these effective endovascular treatments for carotid stenosis has really revolutionized the management? As you're telling us about game-changers, I'd like you to reiterate when you feel it's important to refer to the specialists at UAB Medicine.
Dr Liptrap: So we're happy to see any patients that you may have with a carotid disease. And regarding the new techniques and current techniques that we have, it certainly gives greater options and safer options for patients with this disease. Patients with carotid stenosis who have had a stroke are at continued risk of stroke if it's not treated. And so for patients who cannot undergo a carotid endarterectomy for whatever reason and need to have carotid stenting, TCAR as Dr. Harrigan mentioned has really revolutionized that treatment, because a big issue with carotid stenting obviously is having the emboli break off during the procedure. And having new ways to treat patients that are safer and prevent any complications, obviously, that's always a good thing.
Melanie: And Dr. Harrigan, last word to you. As we're talking about the surgically and medically managed patients with carotid artery disease, what would you like other providers to take away from this episode? What do you feel are some of the most important points we've covered today?
Dr Harrigan: We view carotid stenosis management as a multidisciplinary process. So we in vascular neurosurgery here at UAB work very closely with the UAB Stroke Service in handling patients who have symptomatic disease as well as asymptomatic disease. So we take this multidisciplinary approach to carotid disease very seriously. And we take pride in being able to offer the full spectrum, including medical management to patients with chronic stenosis.
Melanie: Such an interesting topic. Doctors, thank you again for joining us. You are great guests as always. And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB MedCast to refer your patient or for more information on resources available at UAB Medicine, please visit our website at uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.