Carotid Artery Disease and Stroke: Prevention and Treatment | Q&A

Aug 18, 2023

Carotid Artery Disease and Stroke: Prevention and Treatment | Q&A

Professor of Surgery Bruce Perler discusses causes, symptoms, risk factors and treatment of carotid artery disease and stroke.

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14.401 -> I've performed over 1600 carotid and arteritic procedures at Johns Hopkins over

19.073 -> the years, but without question the most rewarding and gratifying part of

23.105 -> my practice in terms of carotid disease, is reassuring patients that they

27.137 -> don't need an operation and they're not at high risk of stroke.

31.78 -> Stroke, in my opinion, is the

33.54 -> most devastating complication of cardiovascular disease.

37.2 -> It devastates lives.

39.45 -> One year after stroke, two-thirds of

41.53 -> survivors are left with significant functional deficits.

44.84 -> That's our third leading cause of death, our second leading cause of

47.73 -> dementia and the number one cause of adult disability in America today.

52.16 -> And patients are terribly scared when they hear the word stroke.

55.97 -> I see lots and lots of patients, almost on a weekly basis,

59.08 -> who have had a duplex scan, often in a community screening, a study.

63.22 -> And they have a piece of paper that says

64.78 -> they have carotid disease and they're at risk of stroke.

67.18 -> And we see them.

68.54 -> We evaluate them comprehensively, we get a

70.7 -> duplex scan in our accredited vascular laboratory

73.74 -> and find that they only have modest

75.32 -> disease at most and they're best treated medically.

78.39 -> I've got patients like that I've been following for ten or 20 years.

81.83 -> I enjoy performing carotid surgery, but it's terribly gratifying

85.194 -> to be able to put someone's mind at ease.

87.238 -> Tell them they don't need an operation, and they're not at risk of stroke.

91.005 -> [MUSIC]

94.74 -> The term vascular surgeon is really a misnomer because

97.684 -> vascular surgeons do much, much more than conventional surgery.

101.38 -> We diagnose the condition, we perform the duplex scans in our vascular laboratories.

106.38 -> And we perform both carotid and

108.11 -> arterectomy, and carotid angioplasty and stent procedures.

111.31 -> I think it's, it's sort of important to emphasize

114.08 -> that only when a patient sees a physician or group

116.58 -> of physicians who have all the tools in their

118.58 -> toolbox, we have all of the modalities of treatment available.

122.2 -> Only then will that patient be guaranteed that they're gonna get the treatment that

126.247 -> they're most in need of rather than

127.957 -> a particular treatment that a particular specialist offers.

130.995 -> [MUSIC]

135.154 -> The carotid arteries are the two major blood vessels in the neck,

138.839 -> one on each side that deliver blood and oxygen to the brain.

142.225 -> Carotid artery disease refers to the progressive blockage

145.825 -> of these vessels due to the build up of

148.057 -> plaque made up of cholesterol, calcium, fibrous tissue and

151.801 -> blood clots that deprives the brain of adequate oxygen.

155.339 -> [MUSIC].

160.506 -> There are over 700,000 strokes that occur each year in the United States.

164.91 -> And carotid artery disease is one of the

166.67 -> most important and completely preventable causes of stroke.

171.34 -> Stroke occurs when these blockages in the carotid

174.06 -> artery limit blood flow so that cell death occurs.

177.38 -> Or when bits of the plaque break off and lodge in the tiny vessels in the

180.57 -> brain, again limiting oxygen supply, leading to cell

183.155 -> death and the development of a clinical stroke.

185.533 -> [MUSIC]

190.716 -> The prevalence of carotid artery disease increases with advancing age.

195.34 -> Although it can occur in younger individuals,

197.43 -> most patients are over the age of 65.

200.03 -> Other factors that contribute to the development of carotid

203.45 -> artery disease include high blood

205.11 -> pressure, hypertension, elevated cholesterol levels.

209.72 -> Diabeties and certainly cigarette smoking.

212.03 -> [MUSIC]

216.495 -> The most appropriate treatment for a patient

218.775 -> with carotid artery disease depends on two factors.

221.61 -> First, the severity of the blockage itself and the patient's symptomatic status.

226.87 -> The severity of the blockage is best determined

229.04 -> by performance of a carotid duplex ultrasound examination.

232.68 -> This is a noninvasive, relatively quick, and relatively inexpensive test

237.74 -> that not only tells us how severe the artery is blocked.

241.13 -> But also allows us noninvasively to examine the plaque, and

244.53 -> the character of that plaque, which has future prognostic significance.

249.02 -> The other issue is the patient's symptomatic status.

251.33 -> Most patients with carotid disease are completely asymptomatic when they present.

256.63 -> And when we know about them, it's typically because they've had a [UNKNOWN]

259.01 -> or a sound in the neck that was picked up by a stethoscope.

263.6 -> For those patients, unless the blockage is

265.64 -> really severe, the optimal treatment is medical management.

268.8 -> This includes the use of aspirin which is

270.77 -> a powerful anti platelet or anti clotting drug.

274.1 -> Use of stat medications which not only

276.27 -> lowers cholesterol levels but actually stabilize the

279.38 -> plaque itself and has been shown in

281 -> numerous studies to reduce stroke risk long term.

284.43 -> And good blood pressure control and again certainly stopping smoking.

288.71 -> On the other hand, once a patient has become symptomatic, that is either had a

293.066 -> stroke or a so called mini stroke or

294.98 -> TIA transient ischemic attack, then intervention is required.

298.697 -> [MUSIC]

304.048 -> The standard conventional treatment for symptomatic carotid

307.546 -> disease and also asymptomatic disease that is

310.12 -> very, very severe, that is typically greater

312.76 -> than 80% blocked, is a carotid endarterectomy.

316.37 -> This operation is really the gold standard treatment for carotid disease.

320.78 -> It's been around, it's been performed for more than 50 years.

323.95 -> And it's been highly studied and very well perfected.

327.49 -> In this operation the surgeon makes an incision over

330.14 -> the artery, opens the vessel and directly removes the plaque.

334.17 -> And then repairs the artery.

335.9 -> It can be performed either under general anaesthesia or with local anaesthesia

340.23 -> by numbing the skin, depending upon the surgeon's and the patient's preference.

345.33 -> It takes about an hour to do the procedure, and recovery is very quick.

349.34 -> Most patients are discharged the day after surgery.

352.09 -> [MUSIC]

356.94 -> An alternative to carotid endarterectomy today is carotid angioplasty and stenting.

362.39 -> This is generally reserved for patients considered to be at too high risk

367.44 -> for open surgery and it's, it's an

369.3 -> approach that is still under clinical investigation.

372.53 -> In this procedure, the skin in the groin is numbed up with a local anaesthesia,

376.08 -> a needle is introduced, a catheter is

378.74 -> introduced, and threaded up into the carotid artery.

381.86 -> Dye is injected, and a picture on our turogram

385.22 -> of the carotid artery is obtained, and then a

387.01 -> balloon is inserted and dilated up, to open the

389.82 -> blockage, and then a stent is usual, usually placed.

393.09 -> They hold the blockage open and again after

395.76 -> carotid angioplasty and stent and recovery is very quick.

398.64 -> Most patients go home the day after surgery.

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406.74 -> Recovery from carotid endarterectomy is very rapid.

409.87 -> Really, patients resume their normal activities just a

412.42 -> day or two after being discharged from a hospital.

414.92 -> The one exception is because there's a, an incision in the neck and it may be

418.61 -> a bit sore, we encourage patients not to

420.53 -> drive themselves for about a week or ten days.

423.6 -> Because changing lanes might be a little bit of a challenge in similarly after

427.63 -> carotid angioplasty your stem procedure because the

430.42 -> groin might be a little bit sure.

432.169 -> Again we ask patients not to drive for about a week after the

435.207 -> procedure but generally patients immediately return to

438.183 -> the normal quality and status of life.

440.36 -> [MUSIC]

444.67 -> Although we perform these procedures to prevent stroke, stroke

448.23 -> is one of the potential complications of these interventions.

451.63 -> In a recently completed NIH trial, the Crest

454.61 -> trial, the incidence of stroke was about 2%.

457.59 -> That is one in 50 patients who had a carotid endarterectomy versus

462.672 -> 4%, one in 25 patients who underwent a carotid angioplasty and stent procedure.

466.984 -> [MUSIC]

471.97 -> In general, I like to see my patients a few weeks after surgery just to make sure

476.31 -> the incision's healing after a carotid endarterectomy or the

479.45 -> groin looks okay after a carotid angioplasty extent procedure.

483.53 -> And then, we have the patients return once a year,

485.66 -> and at that time obtained a carotid duplex ultrasound examination.

489.81 -> Not only to look at the artery that we

491.56 -> treated, but also to look at the other carotid artery

494 -> on the other side of the neck to make

495.44 -> certain that it's not developing new disease down the line.

498.17 -> [MUSIC]

502.93 -> It is very important that the carotid

504.883 -> duplex scan be performed in an accredited laboratory.

507.9 -> Ultrasound machines are available in many physician's offices, and healthcare

512.34 -> clinics, and walk in clinics, and these are very critical tests.

516.72 -> The decision as to how we treat a patient is

518.79 -> dependent upon the information that comes out of these tests.

521.66 -> And only when a patient is evaluated in a truly

524.64 -> accredited vascular laboratory that has to meet very rigorous criteria can

528.762 -> they be certain that the information that they're being given

531.71 -> is truly accurate in terms of determining their most appropriate treatment.

535.205 -> [MUSIC]

540.36 -> And as chief of the division of vascular surgery and

542.682 -> endovascular therapy, I'm most proud of the team that we've recruited.

546.69 -> Our vascular team at Johns Hopkins, all of use share a common vision.

550.83 -> We believe our mission is not to take care of disease.

553.88 -> Our mission is to take care of people.

556.95 -> We're all committed to one goal, that is to do the

559.3 -> most appropriate thing to optimize the vascular health of our patients.

563.22 -> [MUSIC]

568.25 -> Johns Hopkins has a well deserved reputation

570.89 -> as an outstanding center for research and teaching.

574.1 -> And we're an international center of excellence in clinical care.

577.48 -> Diagnosing and treating the entire gamut disease from

580.7 -> the various attack to the every day routine processes.

585.02 -> I think sometimes what gets lost in this well-deserved reputation

588.82 -> is the human touch inherent in the care that we deliver.

592.44 -> Johns Hopkins physicians truly care about patients as people.

595.884 -> And that's something that we're most proud of.

597.699 -> [MUSIC]

Source: https://www.youtube.com/watch?v=NE_ose_81Z0