The options include surgery, stenting, or medications. Which is right for you?
The buildup of fat, cholesterol and other deposits on artery walls can block the flow of oxygen-rich blood to organs and tissues throughout the body. When clogs develop in the coronary arteries, the result can be a heart attack. But when obstructions develop in the carotid arteries of the neck, the main hazard is brain attack (stroke). Plaque in a carotid artery can cause a stroke by blocking blood flow to part of the brain, or by breaking loose and completely blocking a smaller vessel in the brain. Symptoms of a pending stroke usually call for treatment to reduce the risk.
Endarterectomy versus carotid stenting
One option calls for opening the artery and removing the plaque—a surgical procedure known as endarterectomy. “Carotid endarterectomy is the gold standard for treating carotid artery stenosis,” says Dr. Michael Belkin, professor of surgery at Harvard-affiliated Brigham and Women’s Hospital. For the best results, it’s crucial to do the surgery only on people with the greatest chance of benefit. Prime candidates include people who have an artery that is more than 50% blocked and who are experiencing stroke-like symptoms. For people without symptoms, the operation may be recommended if they have a blockage of more than 80% but no other major health problems.
Symptoms of pending stroke
Have someone call 911 immediately if you have any of these symptoms:
“If you do this operation in people without symptoms or who are very elderly with other medical problems, you might not get good results,” says Dr. Belkin. In addition, the delicate operation achieves its highest success rate when a highly experienced surgeon is at the helm.
A less invasive option, called carotid artery stenting (CAS), involves inserting a catheter into an artery in the groin, advancing it to the carotid artery, opening the blockage with a balloon, and leaving behind a wire cage (called a stent) to hold the artery open. A drawback of CAS is that the act of pushing the catheter forward may dislodge small plaque particles, which may escape to the brain and cause a stroke, although the use of mesh-like filters in the artery reduces this risk. Surgery releases fewer particles because the artery is clamped before the operation and blood flow to the brain is diverted though a tube known as a shunt. On the positive side, CAS puts less stress on the heart so is often a better option for someone unable to tolerate major surgery.
Neither endarterectomy nor stenting stops the progression of arterial disease, so a future blockage in the artery or stent (known as restenosis) is a concern. However, the rate of restenosis with both procedures appears to be less than 6%—far less than could be expected without treatment.
Choosing a treatment
For some people, neither option is appropriate because the risks of surgery may outweigh the likely benefit, says Dr. Belkin. For them, lifestyle modifications and medicines to prevent stroke may be a more prudent option. Thanks to an improved regimen that combines antiplatelet drugs with statins and blood pressure–lowering medications, nonsurgical treatment is more effective than ever.
Consulting a specialist is definitely the first step if you have been diagnosed with a blockage in the carotid arteries. If your doctor considers you a good candidate for either endarterectomy or a stenting procedure, have him or her recommend a medical center where the operation is performed often (at least once a week) by experienced teams. Ask the surgeon specific questions, such as “How many of these procedures do you perform each year?” and “How well do your patients do afterward?” These are tough questions, but they are important in your decision-making process as an empowered patient.