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About Carotid Artery Disease and Stroke - Prevention and Treatment [Transcript]

Bruce Perler Bruce Perler, MD, MBA Is a vascular surgeon at Johns Hopkins. Watch the video

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Featuring Bruce Perler, M.D., M.B.A., Professor of Surgery, Vascular Surgeon

What is your perspective on managing stroke risk in patients with carotid artery disease?

I’ve performed over 1,600 carotid endarterectomy procedures at Johns Hopkins over the years, but without question, the most rewarding and gratifying part of my practice in terms of carotid disease is reassuring patients that they don’t need an operation and they’re not at high risk of stroke. Stroke, in my opinion, is the most devastating complication of cardiovascular disease. It devastates lives. One year after stroke, two-thirds of the survivors are left with significant functional deficits. It’s our third leading cause of death, our second leading cause of dementia, and the number one cause of adult disability in America today, and patients are terribly scared when they hear the word “stroke.”

I see lots and lots of patients, almost on a weekly basis, who have had a duplex scan, often in a community screening, a study, and they have a piece of paper that says they have carotid disease and they are at risk of stroke. We see them, we evaluate them comprehensively, and we get a duplex scan at our accredited vascular laboratory and find that they only have modest disease at most and they are best treated medically. I’ve got patients like that I’ve been following for ten or twenty years. I enjoy performing carotid surgery, but it’s terribly gratifying to be able to put someone’s mind at ease, tell them they don’t need an operation and they are not at risk for stroke.

What is the role of a vascular surgeon?

The term vascular surgeon is really a misnomer because vascular surgeons do much, much more than conventional surgery. We diagnose the condition, we perform the duplex scans in our vascular laboratories, and we preform both carotid endarterectomy and carotid angioplasty and stent procedures.

I think it’s sort of important to emphasize that only when a patient sees a physician or a group of physicians who have all the tools in their toolbox, who have all of the modalities of treatment available, only then will that patient be guaranteed that they’re going to get the treatment that they are most in need of, rather than a particular treatment that a particular specialist offers.

What is carotid artery disease?

The carotid arteries are the two major blood vessels in the neck, one on each side, that deliver blood and oxygen to the brain. Carotid artery disease refers to the progressive blockage of these vessels due to the buildup of plaque, made up of cholesterol, calcium, fibrous tissue and blood clots, that deprives the brain of adequate oxygen.

What problems can carotid artery disease cause?

There are over 700,000 strokes that occur each year in the United States and carotid artery disease is one of the most important and completely preventable causes of stroke. Stroke occurs when these blockages in the carotid artery limit blood flow so that cell death occurs, or when bits of plaque break off and lodge in the tiny vessels in the brain, again limiting oxygen supply leading to cell death and the development of a clinical stroke.

Who is at risk for developing carotid artery disease?

The prevalence of carotid artery disease increases with advancing age. Although it can occur in younger individuals, most patients are over the age of 65. Other factors that contribute to the development of carotid artery disease include high blood pressure or hypertension, elevated cholesterol levels, diabetes, and certainly cigarette smoking.

How do you determine the best treatment for carotid artery disease?

The most appropriate treatment for a patient with carotid artery disease depends on two factors. First, the severity of the blockage itself, and the patient’s symptomatic status. The severity of the blockage is best determined by performance of a carotid duplex ultrasound examination. This is a non-invasive, relatively quick, relatively inexpensive test that not only tells us how severe the artery is blocked, but also allows us non-invasively to examine the plaque, and the character of that plaque, which has future prognostic significance.

The other issue is the patient’s symptomatic status. Most patients with carotid disease are completely asymptomatic when they present, and what we know about them is because they’ve had a bruit or a sound in the neck that was picked up by a stethoscope. For those patients, unless the blockage is really severe, the optimal treatment is medical management. This includes the use of aspirin, which is a powerful anti-platelet or anti-clotting drug, the use of statin medications, which not only lower cholesterol levels but actually stabilize the plaque itself and have been shown in numerous studies to reduce stroke risk long-term, and good blood pressure control. And again, certainly stopping smoking.

On the other hand, once a patient has become symptomatic, that is either had a stroke or a so-called mini-stroke or TIA – Transient Ischemic Attack – then intervention is required.

Describe the standard surgical treatment for carotid artery disease.

The standard conventional treatment for symptomatic carotid disease, and also asymptomatic disease that is very, very severe that is typically greater than 80% blocked is a carotid endarterectomy. This operation is really the gold-standard treatment for carotid disease. It’s been around – it’s been performed for more than 50 years, and it’s been highly studied and very well perfected.

In this operation, the surgeon makes an incision over the artery, opens the vessel and directly removes the plaque and then repairs the artery. It can be performed either under general anesthesia or with local anesthesia by numbing the skin depending on the surgeon’s and the patient’s preference. It takes about an hour to do the procedure and recovery is very quick. Most patients are discharged the day after surgery.

What are the minimally invasive alternatives to standard surgery?

An alternative to carotid endarterectomy today is carotid angioplasty and stenting. This is generally reserved for patients considered to be at too high risk for open surgery. And it’s an approach that is still under clinical investigation.

In this procedure, the skin and the groin is numbed up with a local anesthesia, a needle is introduced, a catheter is introduced and threaded up into the carotid artery. Die is injected and a picture or arteriogram is obtained and then a balloon is inserted and dilated up to open the blockage. Then a stent is usually placed to hold the blockage open. And again, after carotid angioplasty and stenting, recovery is very quick. Most patients go home the day after surgery.

What can a patient expect after treatment?

Recovery from carotid endarterectomy is very rapid. Really, patients resume their normal activities just a day or two after being discharged from the hospital. The one exception is that, because there’s an incision in the neck and it may be a bit sore, we encourage patients not to drive themselves for about a week or ten days because changing lanes might be a little bit of a challenge.
Similarly, after carotid angioplasty and stent procedure, because the groin might be a little sore, again we ask patients not to drive for about a week after the procedure. But generally, patients immediately return to their normal quality and status of life.

What are the risks associated with treatment?

Although we perform these procedures to prevent stroke, stroke is one of the potential complications of these interventions. In a recently completed NIH trial, the CREST trial, the incidence of stroke was about 2% - that is one in 50 patients – who had a carotid endarterectomy versus 4% - one in twenty five patients – who had a carotid angioplasty and stent procedure.

What follow-up is required for these patients?

In general, I like to see my patients a few weeks after surgery, just to make sure the incision is healing after a carotid endarterectomy or the groin looks okay after a carotid angioplasty and stent procedure. And then, we have the patients return once a year, and at that time we’ll obtain a carotid duplex ultrasound examination, not only to look at the artery that we treated, but also to look at the other carotid artery on the other side of the neck to make certain that it’s not developing new disease down the line.

What is the importance of a certified vascular lab for testing?

It is very important that the carotid duplex scan be performed in an accredited laboratory. Ultrasound machines are available in many physicians’ offices and healthcare clinics and walk-in clinics. These are very critical tests, the decision as to how we treat a patient is dependent up on the information that comes out of these tests. And only when a patient is evaluated in a truly accredited vascular laboratory that has to meet very rigorous criteria can they be certain that the information they are being given is truly accurate in terms of determining their most appropriate treatment.

What do you consider your greatest accomplishment?

As chief of the division of vascular surgery and endovascular therapy, I’m most proud of the team that we’ve recruited – our vascular team at Johns Hopkins. All of us share a common vision: We believe our mission is not to take care of the disease. Our mission is to take care of the people. We’re all committed to one goal: That is to do the most appropriate thing to optimize the vascular health of our patients.

Why should a patient come to Johns Hopkins?

Johns Hopkins has a well-deserved reputation as an outstanding center for research and teaching, and we’re an international center of excellence in clinical care, diagnosing and treating the entire gamut of disease from the very esoteric to the everyday, routine processes. I think sometimes what gets lost in this well-deserved reputation is the human touch inherent in the care we deliver. Johns Hopkins physicians truly care about their patients as people, and that’s something that we’re most proud of.