Vascular surgeon Rebecca Marmor discusses the medical management and surgical treatment options for carotid artery stenosis, and outlines the multidisciplinary care available for this patient population at Johns Hopkins Medicine.
All patients who have carotid stenosis should be on an antiplatelet agent. A baby aspirin, 81 mg every day is our most commonly recommended medication for this purpose. However, for patients who are aspirin intolerant or have other issues with it, there are other alternatives available. Additionally, every patient who has carotid stenosis should be on a statin agent if they're able to tolerate it. I hear a lot from patients now that they previously were on a statin and had an adverse reaction to it or they've read something in the news. I tell them that there is a statin for every patient. Even since I've been doing this, the number of statins available has tripled. Um So we work very closely with our patients, cardiologists and primary care doctors to find uh the appropriate statin and make sure our patients are taking it. Additionally, patients who have carotid artery disease many times have diabetes have high blood pressure and are smoking, managing these patients with good glycemic control, making sure they're on a good anti hypertensive regimen and helping them with smoking cessation aids is of the utmost importance to managing their disease when we think about carotid artery surgery. Uh There's three major surgical options available. The carotid endarterectomy or CE A as we sometimes refer to it as is the gold standard operation for carotid artery revascularization. It's a procedure that we've been doing since the 19 fifties. We make an incision along the patient's neck, go in dissect out their vessels, clamp the vessels, open them scoop out the plaque and then patch the artery uh to close it. It's a very well tolerated procedure. We typically quote a stroke risk of 1 to 3% for patients who do not have symptoms related to their carotid artery disease. Not all patients for a variety of reasons are good candidates for carotid endarterectomy, for patients who are not good candidates for carotid endarterectomy. We have two options. The next option which was developed is the transfemoral carotid stent placement. That's where we make a small incision on the top of the patient's leg and deploy the stent um by going up through their aortic arch. Unfortunately, that procedure has been shown to have a higher stroke risk as compared to the carotid endarterectomies and is uh not used quite as frequently only in very select circumstances. The final option for revascularizing a carotid artery is known as A T car and that's a procedure where we actually deploy the stent into the carotid artery by making a small incision on the patient's neck. The benefit of the T car is that it has a stroke risk, it's thought to be equivalent to that of the carotid an artery of about 1 to 3%. Um and is very well tolerated because we use a flow reversal technique or as we're actually working on the artery, we divert blood flow away from the brain to prevent an embolic stroke. So all patients who come to see me for carotid stenosis, uh need to come with some sort of imaging. The most commonly uh ordered imaging is an ultrasound of the carotid arteries. Um But sometimes we have patients who have either had ac T angiogram or an MRI patients are always surprised. Uh when I tell them that typically recovery from carotid surgery, uh is uneventful, smooth and relatively pain free. Um, in general, patients who have carotid surgery regardless of the type, spend one night in the hospital with us, um to make sure that their neurological exam remains stable and that their blood pressure is well managed. Um, most patients go home the day after surgery, a small number of them will stay, uh for a variety of different reasons. Patients typically go home on Tylenol, only an important thing to know about patients who've had carotid surgery is many of them will have left the hospital on different dosing of their blood pressure medications than what they came in on. And that's because when we manipulate the carotid body, when we deploy a stent in the carotid artery, it's not uncommon for patients, blood pressure to fluctuate. I typically recommend that patients check their blood pressure twice a day for surgery for four weeks. I also recommend that as their blood pressure creeps up after surgery, which it most commonly does that they reach back out to either their primary care doctor or their cardiologist to discuss resuming additional additional medications or changing the dosa around. So as a Hopkins Vascular surgeon, I have the luxury of having several neurologists, cardiologists, anesthesiologists, primary care doctors on speed dial. So the care of carotid artery patients is very subtle, very nuanced. I have to account for their comorbidity which include cardiovascular issues, underlying dementia, kidney issues that they may or may not have. So getting to work closely with a number of different specialists really leads to optimal care for our patients. Um So when patients come to see us in Colombia, they're not just coming to see me, they're getting to have care that's informed by discussions with a multidisciplinary team at Johns Hopkins. We're extremely fortunate to be a participant site in the Crest two trial. The crest two trial is trying to answer one of the most important questions in terms of the management of patients with asymptomatic disease. We're trying to figure out at what threshold of carotid artery stenosis should we recommend surgery for our asymptomatic patients? We know the recommendations for surgical intervention were based off of clinical trials performed in the late 19 nineties and early two thousands. And we know that the number of medications and types of medications have proliferated in the past 20 plus years. We have so many new anti hypertensives, new antiplatelet agents. And perhaps most importantly, we have an entirely new category of drug statins. So crest two is going to answer a lot of important questions and for our asymptomatic patients, we're lucky to be able to offer them participation.