The carotid arteries are two large arteries in the neck that supply blood flow to the brain. With time, these vessels can progressively narrow, usually from cholesterol build up and is called "plaque." Most of the time, the narrowing does not cause any problems, but if the build-up becomes severe or active, it may cause a stroke or transient neurological symptoms.
The Boston Medical Center Stroke and Cerebrovascular Center for carotid artery disease offers advanced medical, endovascular and surgical treatments for patients with carotid artery disease. Interventions offered include:
If the artery is not symptomatic or symptomatic with mild stenosis, aggressive medical therapy is recommended, which is important to prevent future strokes. Medical therapy includes an antiplatelet agent such as aspirin, a lipid-lowering drug such as a statin, and blood pressure lowering therapy. Patients are also strongly counseled to avoid smoking. If a patient has diabetes, then blood sugar control is important.
This is a surgical procedure that opens the artery and removes the plaque, and is typically recommended in patients with severe symptomatic narrowing of the artery.
This minimally invasive procedure is an alternative to surgical opening of the carotid artery, whereby a stent is placed to open the artery via the endovascular route.
Carotid Stenting Procedure
Carotid stenting procedure steps
Carotid artery stenting is performed under monitored anesthesia care with the patient sedated but awake. The femoral artery is accessed in the groin area, usually on the right side. A sheath is placed through which a catheter is placed for diagnostic angiography. This shows the Neurointerventionalist the precise location and degree of narrowing in the artery and the collateral circulation around the brain. Under direct fluoroscopic visualization, a small guide wire is passed beyond the stenosis. This wire may have a built in protection device to collect debris from the revascularization procedure. The next step is placement of the stent over this guidewire and possibly a second angioplasty to secure the stent in place. Any debris collected by the protection device is retrieved, and the catheters are removed. Patients usually spend 3 days in the hospital the first of which is in the intensive care unit for neurological and blood pressure monitoring to prevent reperfusion hemorrhage. Patients are continued on aspirin and Plavix and followed by our staff after discharge from the hospital.
Precautions are taken to avoid potential complications, such as stroke. Angioplasty can cause transient bradycardia due to pressure on the carotid body, and we may administer atropine for heart rate or blood pressure control. Reperfusion syndrome is a rare problem, which may occur in patients who have extremely tight stenosis. The cerebral vasculature loses its normal autoregulation and in some cases patients may develop cerebral edema, and blood pressure control must be strictly regulated. Transient ischemic events are uncommon but can happen despite distal protection devices.
Patients are screened individually for appropriate treatment by a team of physicians including the Stroke Service, Interventional Neuroradiology, Neurosurgery, Neuroradiology and Vascular Surgery. This ensures a patient is selected by proper criteria and receives long-term follow up. Typically, a patient should be symptomatic and have at least 70% stenosis of the affected carotid artery to undergo a procedure to open the artery. Most patients will have undergone MRI/MRA or CTA and carotid/Transcranial Doppler Ultrasound to determine if an artery is narrow.
For more information, please call 617.638.8456.
- Brott TG, Hobson RW, Howard G, et al. Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis. New Engl J Med 2010;363:11-23.
- International Carotid Stenting Study investigators. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomized controlled trial. The Lancet 2010;375(9719)985-997.
- Eckstein HH, Ringleb P, Allenberg JR et al. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomized trial. The Lancet Neurology 2008;7(10):893-902.
- Gurm HS, Yadav JS, Fayad P. et al. for the SAPPHIRE Investigators. Long-Term Results of Carotid Stenting versus Endarterectomy in High-Risk Patients. N Engl J Med 2008;358:1572-9.