Carotid Artery Disease

What is Carotid Artery Disease?

Arteries throughout the body can become narrowed or even occluded (blocked) by a build-up of cholesterol, fat and calcium known as an atherosclerotic plaque. This can occur to the carotid arteries that supply blood to your brain.

The brain is supplied by two large carotid arteries (right and left) which supply the front two thirds of your brain. These carotid arteries pass up each side of the neck and divide into internal and externalcarotid arteries. The internal carotid arteries supply oxygen-rich blood to your brain. The external carotid arteries supply oxygen-rich blood to your face, scalp, and neck. It is the narrowing of the internal carotid artery that is of concern as it supplies the brain itself, especially critical areas that are associated with vision, movement and sensation to your face, arms and legs as well as speech. These internal carotid arteries are often treated for severe narrowing.

The back third of the brain is supplied by two smaller arteries known as vertebral arteries. These form a complicated network of arteries with the internal carotid arteries known as the Circle of Willis inside the base of your skull. These vertebra arteries are only very rarely associated with significant symptoms and rarely need treatment.

The narrowing of the internal carotid arteries in many cases may be associated with no symptoms at all and can be called asymptomatic. However, in some instances can cause:

  • Stroke – a severe medical emergency
  • Trans-ischaemic attack (TIA) known as a “mini stroke”
  • Amaurosis fugax (a painless temporary loss of vision in an eye like a curtain being drawn over it)

What causes Carotid Artery Disease?

Lifestyle conditions are mostly to blame for the damage caused to the arteries.

Major factors that contribute to this damage include:

  • History of smoking
  • High levels of fats and cholesterol in the blood
  • High blood pressure
  • Diabetes
  • Family History

These conditions cause damage to the walls of arteries and as part of the healing process, atherosclerotic plaques form which cause narrowing of the arteries.

Surprisingly, it is not the reduction of flow in the carotid artery that causes strokes or other symptoms in most instances but is in fact small microscopic particles that dislodge from the plaque that travels to the brain (emboli), blocks the microscopic blood supply causing an area of brain to die. This is what a stroke or mini stroke is.

Studies have shown the severity of stenosis is a de-facto measure of the risk of these emboli forming. Mild-moderate carotid disease is very common but largely not of a significant concern beyond closely watching it. It is the severe degrees of narrowing that pose the greatest risk.

What are the signs and symptoms of Carotid Artery Disease?

Carotid artery disease can go undetected (or be asymptomatic) until a problem develops like:

  • Loss of speech – inability to find the correct word or inability to understand speech
  • Visual disturbances or blindness
  • Weakness to face muscles, arm or leg. For example: hand clumsiness or unable to walk
  • Altered sensation in face, arm or leg

These symptoms may last only minutes in a mini stroke or may last for days-weeks or even permanently in a major stroke. The effect of a stroke or mini-stroke may be minor but can be extremely severe or life-changing in many cases.

The brain is “cross-wired” so right carotid disease may cause left sided symptoms or vice versa. Carotid artery disease symptoms rarely effect both sides simultaneously. Dizziness, or loss of consciousness are very rare symptoms of carotid disease.

What are the stages of Carotid Artery Disease?

Carotid Artery Disease often progresses very slowly over many years and is asymptomatic for a very long time. Once detected, CAD should be monitored on a regular basis by ultrasound and under the guidance of a vascular surgeon. This way, if it progresses to a point where the risk of stroke is greater than the risks associated with surgery, appropriate surgery can be performed in a timely fashion.

What should I do?

Carotid Artery Disease should not be left unassessed or unmonitored. It is best to be proactive in seeking regular check-ups with your GP, especially if you are in the risk groups mentioned above. Sometimes, if you have other vascular problems, or even heart problems, your doctor will look specifically for Carotid Artery Disease during an examination, because if you have blockages in some arteries you are at increased risk of having blockages in others.

This will normally result in you being sent to have an ultrasound called a ‘Carotid Ultrasound’.

What if I don’t have my Carotid Artery Disease treated?

Some people with Carotid Artery Disease do not require intervention because it never progresses to a point where intervention is warranted.

However, everyone with significant Carotid Artery Disease should be under surveillance to monitor whether the disease is progressing or not, so that treatment can be provided when appropriate. In most cases this becomes a decision to when the risk of the narrowing causing a stroke exceeds the risks of treating it. Dr Ponosh will discuss this at length with you.

Carotid Artery Disease Treatment Options

Conservative management

If your tests suggest that the Carotid Artery Disease of low risk and the risks of treatment outweigh the benefits no treatment is required. You will need to simply monitor your symptoms and maintain regular visits with your GP and Dr Ponosh. This may change as time progresses, but the vast majority of patients do not ever need treatment.

Blockage & Stenosis Surgery

Two main surgery methods for treating carotid artery blockage or carotid artery stenosis are:

  • Carotid Endarterectomy
  • Carotid Stent Surgery

Carotid Endarterectomy

This is an open procedure that involves an admission into hospital and a 3-5 day stay in hospital following the procedure. A Carotid Endarterectomy is performed under a general anaesthetic in most circumstances and usually takes approximately 2 hours.

During a Carotid Endarterectomy, the surgeon makes a vertical or curved incision in the neck to expose the affected carotid artery. The aim of this procedure is to clear the build-up from inside the artery, so the surgeon will clamp the artery, make an incision and clean out the problematic plaque. The clean artery will then be closed with a hand sown ‘patch’ made from a synthetic material, and finally, the neck incision will be closed.

Carotid Stenting

Carotid Stenting is the insertion of a stent (metal scaffold) through a small incision in the groin. Special x-ray equipment and dye allow the surgeon to safely move the stent from your groin to your carotid artery in your neck. The stent is designed to keep the artery open and to trap any plaque.

Stenting is minimally invasive, since the surgeon will only make small incisions in the groin area, rather than a larger neck incision.

The surgeon will consider very carefully whether you have disease morphology that is suitable for stenting. Stenting is usually reserved for patients who cannot undergo a Carotid Endarterectomy.

Stenting is performed under angiographic control, with a local anaesthetic and sedation and usually takes approximately 2 hours. The hospital stay and admission is similar to the Carotid Endarterectomy.

Risks of Carotid Disease Treatment

General risks include:

  • Infection – severe infections are very rare
  • Scarring – Carotid Endarterectomy will leave a scar to the neck that over time will become less noticeable.
  • Operative Risks – include heart attacks, lung and bladder infections, deep vein thrombosis

Specific risks of Carotid Endarterectomy include:

  • Stroke – small risk during the procedure cause by reduced blood supply to the brain during the procedure (many techniques are used to reduce this risk), clot forming in the treated carotid, dislodged plaque during the procedure. These events may be temporary or permanent, minor or severe. The risk of stroke in patients with symptomatic carotid stenoses is 30 times greater than the risk of stroke caused by the procedure.
  • Numbess – patchy numbess to the neck and ear is very common. This may be longstanding but is of no concern.
  • Nerve injury – several large nerves travel adjacent to the carotid artery. Damage to these is very rare but can be associated with voice changes or issues with tongue movement. In most cases if it does occur it is transient resolving over a few days. Permanent injury is very rare.
  • Bleeding – rare but a re-operation may be required if it occurs.
  • Re-narrowing – can occur over the years following treatment

Specific risks of Carotid Endarterectomy include:

  • Groin bruising
  • Damage to the artery in the groin that may need surgery or further treatment to repair.
  • Stroke – as per carotid endarterectomy
  • Allergy to dye
  • Kidney impairment from dye – very rare

After treatment

Unfortunately, Carotid Artery Disease cannot be cured, but rather, treated with surgery, adjustment of lifestyle factors and the taking of blood thinning medications. Sometimes, even with diligent following of the doctor’s instructions and good management of lifestyle factors, the disease can recur, so it is important to have ongoing surveillance with your Dr Ponosh.

This will usually involve an ultrasound of the carotid arteries, along with consultation. By doing this on a regular basis, you and your doctor can identify if your disease is recurring or progressing and offer adjustments to your treatment.

Seeing Dr Ponosh

In order to secure an appointment with Dr Ponosh, you will require a referral. Your GP may directly contact Dr Ponosh’s office directly or provide you with a referral to contact the office yourself. Dr Ponosh’s caring and helpful staff will walk you through the process of making an appointment. His staff may also contact you directly. For further information regarding referrals, click here.

When you see Dr Ponosh, he will undertake a full history and appropriate examination. In many instances (if required), he will order appropriate tests before he sees you to streamline your management and avoid unnecessary appointments. These tests are bulk billed at all times if possible. These tests may include ultrasounds, CT scans or blood tests. In some cases, additional tests and appointments may be required.

Based upon Dr Ponosh’s expert review, an appropriate treatment plan will be suggested and explained to you in an open, straight-forward, jargon-free manner with all options and questions addressed.

If you have any questions, please do not hesitate to contact our friendly team on (08) 9386 6200.