Treatment of Carotid Artery Disease: Stents or Surgery
20
Sep
Carotid artery disease is responsible for 10-20% of strokes. The disease is caused due to narrowing of the carotid arteries due to deposition of cholesterol in the vessel walls. Damage to the wall may cause further narrowing by formation of blood clots. This deposition can be removed surgically by carotid endarterectomy or it can be mitigated by placement of a stent ( a tube like structure that holds helps in keeping the artery open).
- Carotid endarterectomy: Endarterectomy refers to the removal of material inside the vessel. This is a surgical procedure done under general anaesthesia. Your surgeon will make an incision in your neck and reach the affected carotid artery. The artery is then opened and the cholesterol deposit and the blood clot are scooped out after which the artery is closed. A drain may be left in place in some cases.
- Carotid artery stenting: In this procedure a thin tube (catheter) is introduced into the artery in your groin. Under x ray monitoring the catheter reaches the narrowed artery. Once the catheter is in its place its tip is expanded for a few seconds to widen the narrowed artery. A stent is then introduced to ensure that the artery remains open. Some stents might also have drugs in them that prevent narrowing of the artery in the future.
Indications for Carotid Surgery and Stents
- Carotid endarterectomy (CEA): surgery causes substantial benefit in individual with 70% narrowing in the carotid artery. Studies have shown that this procedure has the greatest benefits when performed within 2 weeks on onset of symptoms of TIA or stroke. Hence it is indicated in individuals with recent symptoms and high grade of narrowing. There isn’t enough evidence for recommending the surgery to asymptomatic patients without high grade of narrowing.
- Carotid endarterectomy is especially suggested in people with tortuous blood vessels which might make access to the carotid artery difficult with a catheter.
- Carotid artery stenting (CAS): studies have shown that in most cases CAS and CEA are equally efficacious. CAS has the advantage of being less invasive. This procedure is preferred when then narrowing in the artery is nearer to the base of the skull. Individuals with a contraindication for surgical procedures are advised to have CAS instead.
Complications of Carotid Surgery and Stents
- Stroke: although these procedures are a way to prevent occurrences of stroke in the future, some individuals may develop a stroke after a CEA. It is the second most common cause of death after a CEA. Studies have shown that the rate of stroke following a CEA is less than 3% in previously asymptomatic individuals and less than 5% in previously symptomatic individuals. They may be caused due to fragments of the deposits which may get dislodged during the surgery, or improper flushing during the surgery or relative low blood pressure during the procedure.
- Myocardial infarction or commonly known as heart attack is a complication seen in less than 2% of the individuals. It is seen more commonly after a CEA compared to CAS.
- Hyperperfusion syndrome: an uncommon complication of CEA. There is bleeding in the brain after the narrowing of the carotid artery is corrected, accompanied by seizures and headache. This complication is more commonly seen in individuals with high grade of narrowing. Severe headache following the procedure should be immediately reported to the doctor because it may be an indication of bleeding inside the brain.
- Cervical hematoma: a post operative blood clot in the neck is seen in about 3.4% of people following a CEA. The blood clot can have disastrous consequences if it compresses the airways. When there is a significant hematoma, the patient is immediately taken back to the operation theatre and re exploration of the neck is done, this can be potentially lifesaving.
- Nerve injury: occurs in 5% of patients following a CEA.
- Infection of the surgical sight: with increased advancement in sterilisation techniques this is an uncommon complication. When they do occur, they are generally superficial and self limiting.
- Restenosis: restenosis means narrowing of the artery following the surgical procedure. The percentage of individuals affected range from 2.6 to 10% at 5 years. Patients below the age of 65 years and women are more likely to experience this complication.
Recovery After Carotid Surgery and Stents
- Carotid endarterectomy: most individuals are discharged from the hospital about 48 hours after the surgery. After the surgery you will be advised to keep the wound clean with mild soap and water. You might experience some pain at the site of the surgery. If you have had a stroke you will be advised not to drive for at least a month after it. Most individuals are able to return to work in 3-4 weeks post surgery.
- Carotid artery stenting: after the procedure you will be kept for observation in the hospital for 24-48 hours. If your vitals are normal you will be free to go home. Your doctors will advise you to keep the wound site clean and dry. You may experience some pain at the wound site, which is a normal part of the healing process. It is advisable to avoid overusing the leg from where the artery was used to gain access to the carotid vessel. Avoiding strenuous exercise for 5-7 days post procedure will help you have a smooth recovery period.
Prognosis After Carotid Surgery and Stents
- About 2.6-10% of individuals have narrowing of the carotid artery following the procedure. The overall prognosis depends on the accompanying risk factors like hypertension, diabetes, pre existing heart disease, age and gender.
Resources:
