Journal of Vascular and Endovascular Therapy

A narrowing of the carotid arteries, the two primary arteries that deliver oxygen-rich blood from the heart to the brain, is known as carotid stenosis. Carotid stenosis, also known as carotid artery disease, is caused by plaque formation (atherosclerosis) inside the artery wall, which restricts blood flow to the brain. Treatment seeks to lower the risk of stroke by preventing blood clots and managing or eliminating plaque builds up. Fatty deposits (plaques) obstruct the blood vessels that supply blood to your brain and head, causing carotid artery disease (carotid arteries) [1]. The obstruction raises your chances of having a stroke, which occurs when the blood supply to the brain is cut off or severely diminished. Carotid artery disease is usually treated with a mix of lifestyle changes, medication, and surgery.

Carotid stenosis is a narrowing of the carotid arteries that occurs as a result of atherosclerosis. The interior walls of healthy arteries are flexible and smooth. Plaque can build up as we age due to hypertension and minor damage to the blood vessel wall. Plaque is a gummy mass made up of fat, cholesterol, calcium, and other fibrous matter.

Symptoms

Until the artery becomes significantly restricted or a clot occurs, most persons with carotid stenosis have no symptoms. A ministroke, also known as a transient ischemic attack, is the most common cause of symptoms (TIA). When blood supply to the brain is temporarily disrupted and then restored, TIAs occur [2]. The symptoms usually last a few minutes before disappearing completely and the person returning to normal. TIAs should not be ignored; they are a warning sign that an ischemic stroke with permanent brain damage is imminent.

Causes

The most common cause of carotid artery disease is atherosclerosis. It can start as early as early adulthood, although it usually takes decades for symptoms to appear. Some people develop atherosclerosis in their thirties, while others develop it in their fifties or sixties. High blood pressure, diabetes, smoking, and high cholesterol – specifically "bad" cholesterol or lowdensity lipoprotein – all cause damage to the inner wall of the artery (LDL). Obesity, coronary artery disease, a family history of carotid stenosis, and advanced age are all risk factors.

Affected

Carotid stenosis affects more people as they get older. Men are more at risk than women before the age of 75. A person with high cholesterol, high blood pressure, and smoking is eight times more likely than someone without these risk factors to develop atherosclerosis. Each year, more than 500,000 new strokes occur in the United States, with carotid stenosis accounting for 20 to 30 percent of them.

Diagnosis made

A stethoscope may be used to listen to the carotid artery for a swishing noise known as a "bruit." A bruit could be an indication of atherosclerosis-related turbulent blood flow. To detect narrowing of the carotid arteries, one or more diagnostic tests are used. A doppler ultrasonography of the neck, a CT angiogram (CTA) of the neck, magnetic resonance angiography (MRA), or a cerebral angiogram are all used to identify carotid stenosis. Multiple minor strokes can also be detected using imaging. If tests reveal reduced blood flow in one or both carotid arteries, doctors can diagnose carotid stenosis. A neurosurgeon may be referred to you for a surgical consultation.

Surgery

The goal of surgery is to prevent stroke by removing or decreasing plaque buildup and widening the artery lumen to allow more blood to flow to the brain.

Carotid endarterectomy

To remove the plaque, an open operation is required [3]. The carotid artery is located by a skin incision in the neck. To block blood flow, temporary clamps are placed across the artery above and below the stenosis. During this time, blood flow to the brain is carried through the carotid artery on the other side of the neck. Over the blocked spot, the surgeon makes an incision in the artery.

It's also indicated for those who don't have any symptoms but have a blockage of more than 60%. Over a five-year period, surgery reduces the risk of stroke by 6.5 percent in individuals with mild blockage of 50 to 69 percent. The risk of stroke is lowered by 80% in patients with a high-grade blockage of greater than 70%.

Carotid angioplasty / stenting

It's done in a radiology suite during an angiography. In the groyne, a flexible catheter is placed into the femoral artery. It travels via the bloodstream and into the carotid artery after passing through the heart. Then, across the plaque, a tiny catheter with an inflating Angioplasty / stenting is usually recommended for individuals who have: 1) a moderate to high-grade carotid stenosis of more than 70%; 2) various medical problems that enhance the risk of surgical complications; 3) recurring stenosis; or 4) stenosis caused by previous radiation therapy.

Carotid artery bypass

The saphenous vein in the leg or the ulnar or radial arteries in the arm are used to harvest a length of artery or vein from somewhere else in the body. Blood flow is diverted (bypassed) through the vascular graft, which is attached above and below the blockage. When the carotid artery is completely blocked, bypass surgery is usually utilised (carotid occlusion).

References

1. Endarterectomy for Asymptomatic Carotid Artery Stenosis, (1995) Executive committee for the asymptomatic carotid atherosclerosis study. Jama 273:1421-1428.
2. Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, (1998) Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med 339:1415-1425.
3. HobsonII RW, Mackey WC, Ascher E, Murad MH, Calligaro K.D, (2008) Management of atherosclerotic carotid artery disease: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg 48:480-486.