Angioplasty and stent placement - carotid artery

You have an artery on each side of your neck called the carotid artery. This artery brings needed blood to your brain and face.

The blood flow in this artery can become partly or totally blocked by fatty material called plaque. A partial blockage is called carotid artery stenosis (narrowing). A blockage in your carotid artery can reduce the blood supply to your brain. A stroke can occur if your brain does not get enough blood.

There are two invasive ways to treat a carotid artery that is narrowed or blocked. One is surgery called endarterectomy. The other is a procedure called carotid angioplasty with stent placement.

Watch this video about:Balloon angioplasty - short segment

Description

Carotid angioplasty and stenting (CAS) is done using a smal surgical cut.

• Your surgeon will make a surgical cut in your groin after using some numbing medicine. You will also be given medicine to relax you.
• The surgeon places a catheter (a flexible tube) through the cut into an artery. It is carefully moved up to your neck to the blockage in your carotid artery. Moving x-ray pictures (fluoroscopy) are used to see the artery and guide the catheter to the correct position. live x-ray pictures to see your artery. 
• Next, the surgeon will move a wire through the catheter to the blockage. Another catheter with a very small balloon on the end will be pushed over this wire and into the blockage. Then the balloon is inflated.
• The balloon presses against the inside wall of your artery. This opens the artery and sends proper blood flow to your brain. A stent (a wire mesh tube) may also be placed in the blocked area. The stent is inserted at the same time as the balloon catheter. It expands with the balloon. The stent is left in place to help keep the artery open.
• The surgeon then removes the balloon.

Why the Procedure is Performed

There are two invasive ways to treat a narrowed or blocked carotid artery. One is a surgery called endarterectomy. The other is carotid angioplasty with stent placement.

Carotid surgery (endarterectomy) is a safe surgery and is almost always the first choice. This is because there is a higher chance of having a stroke during or soon after angioplasty procedure than there is with the open surgery.

As a result, carotid angioplasty and stenting is most often used only when the patient is too ill to have carotid endarterectomy. Other factors may make angioplasty better choice for treatment. These include which part of the carotid artery is narrowed or whether someone has had neck surgery in the past.

For more information see: Carotid artery surgery

Risks

Risks of carotid angioplasty and stent placement are:

• Allergic reaction to dye 
• Blood clots or bleeding at the site of surgery
• Brain damage
• Clogging of the inside of the stent (in-stent restenosis)
• Heart attack
• Kidney failure (higher risk in people who already have kidney problems)
• More blockage of the carotid artery over time
• Seizures (this is rare)
• Stroke is more likely with carotid artery angioplasty than with carotid endarterectomy

Before the Procedure

Your doctor will do a thorough physical exam and several medical tests.

Always tell your doctor or nurse what drugs you are taking, even drugs, supplements, or herbs you bought without a prescription.

During the 2 weeks before your surgery:

• Days before the surgery, you may have to stop taking drugs that make it harder for your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), clopidogrel (Plavix), naprosyn (Aleve, Naproxen), and other drugs like these.
• Ask your doctor which drugs you should still take on the day of your surgery.
• If you smoke, you need to stop. Ask your doctor or nurse for help quitting.
• Always let your doctor know about any cold, flu, fever, herpes breakout, or other illness you may have before your surgery.

Do NOT drink anything after midnight the night before your surgery, including water.

On the day of your surgery:

• Take the drugs your doctor told you to take with a small sip of water.
• Your doctor or nurse will tell you when to arrive at the hospital.

After the Procedure

After surgery, your doctor may want you to stay in the hospital overnight so that nurses can watch you for any signs of bleeding, stroke, or poor blood flow to your brain. You may be able to go home the same day if your procedure is done early in the day and you are doing well.

Outlook

Carotid artery angioplasty may help lower your chance of having a stroke. But you will need to make lifestyle changes to help prevent plaque buildup, blood clots, and other problems in your carotid arteries over time. You may need to change your diet and start an exercise program if your doctor tells you exercise is safe for you.

Alternative Names

Carotid angioplasty and stenting; CAS; Angioplasty - carotid artery

References

International Carotid Stenting Study Investigators. Dobson EJ, Featherstone RL, Bonati LH, van der Worp HB, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet. 2010;375:985-997.

Murad MH, Shahrour A, Shan ND, et al. A systematic review and meta-analysis of randomized trials of carotid endarterectomy vs. stenting. J Vasc Surg. 2011 Mar;53(3):792-7.

Eisenhauer AC, White CJ, Bhatt DL. Endovascular treatment of noncoronary obstructive vascular disease. In: Bonow Ro, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, Pa:Saunders Elsevier;2011;chap 63.

Update Date: 6/18/2012

Updated by: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine. Michael A. Chen, MD, PhD, Assistant Professor of Medicine, Division of Cardiology, Harborview Medical Center, University of Washington Medical School, Seattle, Washington. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.