Each side of the neck has an artery called the common carotid. Each common carotid splits into two branches -- the internal branch, which brings oxygen-rich blood to the brain, and the external branch, which brings blood to the face. Blockages can occur in the carotid arteries, decreasing the amount of blood flow to the brain. The most common cause of this blockage is fatty deposits (atherosclerosis) accumulating in the walls of the arteries. As deposits continue to build within the arterial wall, the internal diameter of the vessel decreases, blockage results, and the blood flow to the brain is jeopardized. More importantly, the turbulant flow of the blood may lead to small clots forming which may then pass into the blood circulation of the brain and cause a stroke. This may also occur if an atherosclerotic plaque ruptures and its internal contents wash upstream into the brain. Stroke from any cause represents the third leading cause of death in the United States. Half a million new strokes occur each year in the United States, resulting in approximately 150,000 deaths. Stroke is the leading cause of serious long-term disability in the United States.There is a benefit of cleaning out the arteries in the neck to prevent strokes, once the blockage becomes significant.

Atherosclerosis is a degenerative disease of the arteries resulting in plaques consisting of necrotic cells, lipids, and cholesterol crystals. Scientists think the disease starts when the very inner lining of the artery (the endothelium) is damaged. High blood pressure, high levels of cholesterol and triglycerides in the blood, and smoking are believed to lead to the development of plaque.

Because symptoms may not be evident, at risk patients should be encouraged to get screened for carotid artery disease. Risk factors are similar to those for coronary artery disease and include family history, age, smoking, hypertension, hyperlipidemia, and smoking. One common finding on exam is a bruit (flow murmur in the carotid artery heard with a stethoscope by your physician on physical examination). Symptomatic events that are suggestive of carotid artery disease include TIA's (Transient Ischemic Attacks), Amaurosis Fugax, and Strokes. A TIA will typically last for 15 minutes, but may go for hours. neurological signs and symptoms associated with TIA include dysphasia, contralateral hemiparesis, and paresthesia. Temporary paresis most commonly involves the contralateral arm, leg, or both face and arm, or both arm and leg. Numbness typically involves the contralateral hand, foot, face, and contralateral half of the tongue. Amaurosis fugax is a painless, monocular loss of vision, which may be total or sectorial. This is a traditional blackout of the patient’s vision. Amaurosis fugax can occur in isolation, antecedent, or crescendo and is unprovoked and unpredictable. Vision loss typically lasts only seconds, but may last for hours and will resolve completely.

The patient with hemispheric TIA has a 25 percent mortality rate within one month, 33 percent within six months, and 60 percent within seven years. To lessen this risk, it is important to diagnose a surgically correctable lesion such as a carotid plaque. The initial diagnostic test is an ultrasound of the carotid arteries. Ultrasound makes it possible to characterize the plaque within the carotid bifurcation and to determine the hemodynamic effect of the plaque on blood velocities within the extracranial vessels. This can then be followed up by arteriogram or CT angiography, if necessary, to further define the anatomy before surgery is performed.

Indications for carotid endarterectomy have engendered considerable debate among experts and have resulted in publication of retrospective reviews, natural history studies, audits of community practice, position papers, expert opinion statements, and finally prospective randomized trials. The American Heart Association assembled a group of experts in a multidisciplinary consensus conference to develop an outline of indications for carotid artery surgery. Available literature includes considerable overlap in the percent of stenosis used as the threshold for carotid endarterectomy. In general, symptomatic patients with greater than 50% stenosis and healthy, asymptomatic patients with greater than 60% stenosis warrant consideration for carotid endarterectomy. If the blockage in the vessel is greater than 70%, then the benefits of surgery are even more apparent. In general, surgery is not performed once the blood vessel is completely occluded or the blockage is less than 50%.

Although local anesthesia has the advantage of allowing direct evaluation of the patient's neurologic status without sophisticated monitoring, general anesthesia has the advantage of improved airway control and patient comfort during prolonged operations and is most commonly used. An incision is made over the border of the sternocleidomastoid muscle and carotid bifurcation. The artery is identified and dissected free from surrounding structures taking care to avoid injury to these nerves and blood vessels. Once the vessel is free then the patient is given a blood thinner and the artery clamped and opened. A shunt may sometimes be used. The endarterectomy is carried out in a smooth plane in the media of the artery. The most important aspect of this portion of the procedure is to obtain a smooth, tapering endpoint on the internal carotid. Occasionally, tacking sutures will be required to accomplish this. The endarterectomy is closed either primarily or with a patch and doppler study is used to confirm the technical result. A drain may be used during the neck closure.

By restoring adequate blood flow to the internal carotid artery, strokes can be prevented. This may be accomplished either by a surgery called endarterectomy or a procedure known as angioplasty with stent placement. Although considered the standard of care, the carotid endarterectomy is not for everyone. Those at risk for surgery include congestive heart failure, recent heart attack, and unstable angina patients. Traditionally used for the heart, this latter procedure is now being used on blood vessels to the brain as well. Stent placement is an alternative to surgery that enlarges the blockage in the artery. Initially it was only used for those too sick to undergo anesthesia and open carotid endarterectomy. This new technique must only be performed by an experienced physician. Physicians at MCVI perform carotid artery stenting in high-risk patients under the leadership of Dr. Maurice Solis, who has successfully completed over 40 carotid stenting procedures in Macon.

After surgery, you are usually observed overnight to watch for any signs of bleeding, stroke, or compromised blood flow to the brain. Erratic blood pressure (requiring monitoring in an intensive care unit) is relatively common, tends to improve within 24 hours, and should not be a cause for concern. Carotid artery surgery usually helps prevent further brain damage and reduces the risk of stroke. However, unless lifestyle changes (like proper diet, exercise when approved by your physician, and stoppage of smoking) are made, plaque buildup, clot formation, and other problems in the carotid arteries can return. Physician evaluation and carotid duplex study is performed after 6 months and then annually as surveillance monitoring.