Surgery for Carotid Artery Disease: Why You Need a Second Opinion

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Being diagnosed with carotid artery disease can be scary, and making decisions about your treatment can be overwhelming.

“When many patients learn they have carotid artery disease, their first thought is often, ‘Oh my gosh, I need to have surgery to fix this right away,’” says Penn neurologist Michael Mullen, MD. “But it’s important to understand your options and take a thoughtful approach.”

Before considering surgery for carotid artery disease, Dr. Mullen urges patients to seek a second opinion from Penn Medicine, particularly if they have not had a stroke or transient ischemic attack (TIA).

“There are a number of conservative treatment options for carotid artery disease. Our experienced team works together to determine the best methods and approaches for even the most complex cases,” says Dr. Mullen. “Treating carotid artery disease is not just about performing a surgical procedure – we think through every option.”

What is Carotid Artery Disease?

Carotid artery disease develops when the carotid arteries – the main blood vessels that carry blood to your brain – become clogged with plaques. These plaques are clumps of fats, cholesterol, calcium and other substances.

Because the carotid arteries carry blood to your brain, carotid artery disease can reduce the flow of oxygen to the brain. If the narrowing of the carotid arteries becomes severe enough to block blood flow, a stroke or TIA can occur. Similarly, if pieces of plaque break off, those can travel to the brain, causing stroke or TIA.

What are the Risk Factors for Carotid Artery Disease?

The leading cause of carotid artery disease is atherosclerosis, which is when plaque builds up and narrow your arteries. Atherosclerosis can be associated with high blood pressure, diabetes and heart disease.

Along with plaque build-up in the arteries, a family history of carotid artery disease, age and genetics are also risk factors. Other health concerns and behaviors, like alcohol use, smoking, obesity and high cholesterol, can increase your risk of carotid artery disease.

What are the Symptoms of Carotid Artery Disease?

Carotid artery disease may be asymptomatic (without symptoms) or symptomatic (with symptoms), explains David Kung, MD, Neurosurgical Director of the Comprehensive Stroke Center at the Hospital of the University of Pennsylvania.

“Many people with carotid artery disease don’t experience symptoms until it becomes severe and leads to a TIA or stroke,” says Dr. Kung. “The symptoms may include vision problems, slurring or garbled speech, a one-sided facial droop, and a weakness in or inability to move limbs.”

Symptoms of TIAs are usually temporary, lasting a few minutes to a few hours. TIAs should be treated as serious medical emergencies requiring immediate medical treatment, because they are strong predictors of future stroke.

If you are not experiencing symptoms of carotid artery disease but have risk factors for the disease, your doctor may perform an ultrasound or other imaging tests of your carotid arteries.

“These tests allow us to see how severe your disease is and if there is a dangerous level of blockage in your carotid arteries,” says Dr. Kung. “We have a collaborative team of experts who work together to then determine the best course of treatment for you.”

Do You Need to Have Surgery for Carotid Artery Disease?

At Penn Medicine, our neurologists and neurosurgeons work with a multidisciplinary team that includes vascular surgeons and interventionists to provide care to patients with carotid artery disease.

If you have had a stroke or TIA, or if you have a severely blocked carotid artery, you may benefit from surgery to remove the plaque. This surgery is called a carotid endarterectomy. This procedure is time-sensitive and should be done soon after the stroke or TIA, with the goal of preventing another stroke.

During this procedure, a surgeon makes a cut in the neck just below the jaw, then opens the carotid artery and carefully removes the plaque. The surgeon then closes the artery – usually with a patch – and the incision with sutures.

Carotid artery stenting is another surgical treatment that is sometimes used to treat carotid artery disease. During this procedure, a surgeon threads a tube or catheter through an artery in the groin or arm and passes it up to the carotid artery. A tiny balloon at the end of the tube is then inflated to enlarge the narrowed portion of the artery. The surgeon then places a small, expandable tube called a stent to keep the artery open.

However, if you have not experienced any symptoms of carotid artery disease, surgery might not be the best treatment option, explains vascular surgeon Benjamin Jackson, MD.

Dr. Jackson, who practices at the Penn Heart and Vascular Center, says, “The rate of stroke in patients who have asymptomatic carotid artery disease is very low. In many cases, we can help these patients manage their disease with conservative options and without surgery.”

He adds, “Data from the ongoing CREST-2 trial may show that surgical intervention is less important in treating carotid artery disease than optimal medical therapies. For many patients, lifestyle changes and medications for carotid artery disease may be the best treatment. This is especially true for patients for whom surgery would be difficult or unsafe, like those who have had prior neck surgery, radiation or heart issues.”

However, Dr. Jackson warns, “Any patient who has had a stroke, mini stroke or TIA should be evaluated for carotid artery disease, usually with a simple, quick ultrasound study. If there is narrowing of the carotid artery, carotid endarterectomy or carotid stenting are very effective at reducing the risk of another or more catastrophic stroke.”

Why Getting a Second Opinion about Surgery for Carotid Artery Disease is Important

“Since we provide personalized treatments tailored to each patient’s needs, getting a second opinion from Penn means you know you’re receiving the best care for your carotid artery disease,” says Dr. Mullen. “Not only are we involved with the latest research, we also have the advantage of a multidisciplinary team who works together on every case.”

This team approach is a big benefit for patients, says Dr. Kung. “Our team spans across neurology, neurosurgery, vascular surgery and radiology, and we work in collaboration with one another on a daily basis. This fosters innovation and gives patients access to expert care with a full range of options beyond surgery.”

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