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

[MUSIC] I’ve performed over 1600 carotid and
arteritic 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 survivors are left with significant
functional deficits. That’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’re at
risk of stroke. And we see them. We evaluate them comprehensively, we get a duplex scan in our accredited vascular
laboratory and find that they only have modest disease at most and they’re best treated
medically. I’ve got patients like that I’ve been
following for ten or 20 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’re not at risk of stroke. [MUSIC] 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 perform both carotid and arterectomy, and carotid angioplasty and
stent procedures. I think it’s, it’s sort of important to
emphasize that only when a patient sees a physician
or group of physicians who have all the tools in
their toolbox, we have all of the modalities of
treatment available. Only then will that patient be guaranteed
that they’re gonna get the treatment that they’re most in need of rather than a particular treatment that a particular
specialist offers. [MUSIC] 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 build up of plaque made up of cholesterol, calcium,
fibrous tissue and blood clots that deprives the brain of
adequate oxygen. [MUSIC]. 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 the 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. [MUSIC] 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, hypertension, elevated
cholesterol levels. Diabeties and certainly cigarette smoking. [MUSIC] 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 noninvasive, relatively quick,
and relatively inexpensive test that not only tells us how severe the
artery is blocked. But also allows us noninvasively 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 when we know about them, it’s
typically because they’ve had a [UNKNOWN] 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. Use of stat medications which not only lowers cholesterol levels but actually
stabilize the plaque itself and has 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. [MUSIC] 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
anaesthesia or with local anaesthesia by numbing the skin, depending upon 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. [MUSIC] 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, it’s an approach that is still under clinical
investigation. In this procedure, the skin in the groin
is numbed up with a local anaesthesia, a needle is introduced, a catheter is introduced, and threaded up into the
carotid artery. Dye is injected, and a picture on our
turogram of the carotid artery is obtained, and
then a balloon is inserted and dilated up, to
open the blockage, and then a stent is usual,
usually placed. They hold the blockage open and again
after carotid angioplasty and stent and recovery
is very quick. Most patients go home the day after
surgery. [MUSIC] Recovery from carotid endarterectomy is
very rapid. Really, patients resume their normal
activities just a day or two after being discharged from a
hospital. The one exception is because there’s a, 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 in similarly after carotid angioplasty your stem procedure
because the groin might be a little bit sure. Again we ask patients not to drive for
about a week after the procedure but generally patients
immediately return to the normal quality and status of life. [MUSIC] 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 25 patients who underwent a
carotid angioplasty and stent procedure. [MUSIC] In general, I like to see my patients a
few weeks after surgery just to make sure the incision’s healing after a carotid
endarterectomy or the groin looks okay after a carotid
angioplasty extent procedure. And then, we have the patients return once
a year, and at that time obtained 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. [MUSIC] It is very important that the carotid duplex scan be performed in an accredited
laboratory. Ultrasound machines are available in many
physician’s offices, and healthcare clinics, and walk in clinics, and these
are very critical tests. The decision as to how we treat a patient
is dependent upon 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 that
they’re being given is truly accurate in terms of determining
their most appropriate treatment. [MUSIC] And 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
use share a common vision. We believe our mission is not to take care
of disease. Our mission is to take care of people. We’re all committed to one goal, that is
to do the most appropriate thing to optimize the
vascular health of our patients. [MUSIC] 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
disease from the various attack to the every day
routine processes. I think sometimes what gets lost in this
well-deserved reputation is the human touch inherent in the care
that we deliver. Johns Hopkins physicians truly care about
patients as people. And that’s something that we’re most proud
of. [MUSIC]

31 thoughts on “Carotid Artery Disease and Stroke: Prevention and Treatment | Q&A

  1. I am extremely scared, and can't get any sleep since my left carotid artery plaque diagnosis recently! I feel like this is a 'death sentence'! Any advice would be welcomed. I'm 52, 5' 8", and generally vigorous and healthy. Gained much weight over the last 8 years, going up to 231 in August. Since then, have lost 23 pounds, I eat healthy, etc. and my cholesterol numbers are better. Doc prescribed 5mg Crestor, but have not taken statin yet. Are statins necessary?

  2. Incidentally, according to my 'carotid report graph', my 'right carotid ICA showed 0-10% stenosis consistent with no visualized plaque and PSV below 105 CM/S' and my 'left carotid ICA showed 20-39% stenosis consistent with visualized plaque and PSV below 105 CM/S'. Is this really bad?! Can this homogenous plaque rupture, or would it need to be more advanced/thicker? And how do I know if the plaque is stable? I wish Cardiologists took the time to explain to us, and allay (or confirm)our fears!

  3. Audiophile, I URGE you to go plant-strong in your diet! Check out Dr. Caldwell Esselstyn Jr.'s awesome work in The China Study along with Dean Ornish M.D.  Plants will clean up our arteries…meat, chicken, eggs and dairy and fish clog up our arteries! Best to you!

  4. I just turned 40 years old, and I have been diagnosed with 2 dissected carotid artires. I stared getting headachs that would not go away and my doctor just treated them. I woke up one day and my head felf like a bowling ball, I could not get up to walk myself, my mom had to take me to the hostiptal where I was diagnosd with 2 dissections and a mini stoke in the back of my head. I still suffer from constant headachs and have speech impedements along with inbalance  issuses. I also have been seen my many docters and finally been recommended to see  a vascular surgan. I am schulded for a angio cathrization in a few weeks. I don't know what to expect and I am a little nervous.

  5. Just had a stroke 3 weeks ago from blocked artery, 80-90% Having surg in 2 days.  Had ultrasound 4 years ago with nothing showing.  In that time has increased dramatically. Vascular surgeon and cardiologist have listened and no swooshing sounds. I guess I have a a silent one. LIttle to no lasting effects from the stroke but this is scaring the hell out of me. I am sleeping more than being awake. Don't know if I will have another stoke before surg. I am just so tired all the time. I am afraid to fall asleep since not knowing If I will wake up again. Can't wait till this is over to try and lead a somewhat normal life again. Always exercised and watched my diet. I  feel so weak and helpless now.

  6. I had bypass last year was told my veins were so small that they could only use one of them and a memory gland. Recovery is very difficult but results have been horrible 7 stents 3 heart attacks. The vein that was removed from my leg has collapsed over and over . What are my options? Are there artificial veined that can be grafted in a bypass.

  7. My dad has 95 blockage in right and 70 on left. 85 yrs old but keep having mini strokes and symptoms. should be consider surgery?

  8. I'm almost 52 yrs old and just had surgery . The seriousness of this procedure 😑😑😑😑😑😑😑👼

  9. Open Google Doc Rajendra sheregar And see images videos litreture medical science institution cardiac surgeries and multìspeciality NECK VESSEL TRAUMA SURGERY

  10. My dad has 100% stenosis of the right carotid artery, and 50-69% stenosis of the left. This will be his second surgery to fix the left. It is an issue every person on his side of his family has had.

  11. Why not advise patients to stop ingesting cholesterol and move to a healthy whole-food plant-based diet? Or would that be bad for business?

    There's little evidence that stents help. They may actually increase mortality:

  12. temporary loss of sight in right eye, 3 times in three weeks, all night in the ER and the next day, to find 90% blockage in both arteries, Im only 52, so Doctor will cut and scrap right side first, then the left weeks later, this is scary for me, Bend Oregon St. Charles (CED) I believe is the procedure. and Im told could hit two nerves which could cause permanent damage.

  13. Dear all …actually I can't speak English well I am from Africa any way my mother had problems like she can speak well she can't walk properly and I thought she is depressed but later one she made scan and doctor told her she have brain vessels left side block. I am worried. My question is if she make surgery is that possible she can be recover the same mother 2 years ago means she can speak properly and walk I am really depressed looking adivces

  14. This is priceless, clearly presented information. This doctor is A+ at explaining this. Many thanks.


  16. Just wonderful, been searching for "can you reverse plaque buildup in your arteries?" for a while now, and I think this has helped. Have you ever come across – Venharlotte Renenry Scheme – (search on google ) ? Ive heard some interesting things about it and my brother in law got cool success with it.

  17. Just wonderful, I been tryin to find out about "how to remove plaque from arteries mayo clinic" for a while now, and I think this has helped. Have you heard people talk about – Venharlotte Renenry Scheme – (do a google search ) ? Ive heard some great things about it and my cousin got amazing success with it .

  18. This was great, thanks, I have been researching "how to naturally unclog arteries" for a while now, and I think this has helped. Ever heard of – Venharlotte Renenry Scheme – (Have a quick look on google cant remember the place now ) ? Ive heard some interesting things about it and my colleague got great results with it.

  19. This is glorious, I been tryin to find out about "asparagus arteries" for a while now, and I think this has helped. Ever heard of – Venharlotte Renenry Scheme – (search on google ) ? Ive heard some extraordinary things about it and my m8 got excellent success with it.

  20. Over the last 23 years, I have performed over 100,000 carotid duplex scans, in the "screening environment" that he gave absolutely ZERO credit to. Shame on you sir, for negatively generalizing, qualified techs in the field, who are identifying significant, asymptomatic, carotid stenosis in people, who have no idea that they may be walking time bombs, because your stethoscope could not detect a carotid bruit. WE are the warriors, making a difference in helping educate people, and giving them access to these scans, that they would not normally have, due to high costs, and refusal of insurance companies to pay doctors to order them, until someone has symptoms, IF they are lucky enough to have symptoms, which most DO NOT.

  21. was told 80 % blockage by duplex and told would get e more accurate result from Cat scan angiogram. report only says diameter at maximal stenosis roughly 1.5mm, corresponding to a 80-90% stenosis by NASCENT criteria No occlusion. What do i do next ?

    if 80 % i think i would pass on the endarterectomy but at 90 percent i might risk the surgery. how do i get a better "estimate" is MRI better. Anyone ?

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