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Daniel Nelson, MD
Daniel Nelson, MD, Doctor (MD)
Category: Health
Satisfied Customers: 258
Experience:  Licensed MD. Mayo Clinic Rochester trained physician in Internal Medicine - Critical Care Medicine.
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Is there a way to unblock a very slightly blocked carotid ...

Resolved Question:

Is there a way to unblock a very slightly blocked carotid artery without surgery?
Submitted: 6 years ago.
Category: Health
Expert:  Daniel Nelson, MD replied 6 years ago.
Can you tell me the percentage of the occlusion estimated by either duplex carotid ultrasound or carotid angiogram? Do you have any symptoms of carotid disease, such as ministrokes (called TIA or RND), a grey cloud coming over your visual field in that eye on the same side as the carotid artery in concern?
Customer: replied 6 years ago.
I don't have a percentage. It was done by Lifeline
screening and they said it was mild/moderate.
Customer: replied 6 years ago.
Reply to XXXXX XXXXX, MD's Post: I have none of the symptoms you describe
Expert:  Daniel Nelson, MD replied 6 years ago.

Dear Lindran,

I believe that Life Line Screening services performs a simple Doppler colorflow ultrasound (aka duplex carotid ultrasound). They should have been able to provide a percentage occlusion value by this type of testing. Your question is, can a very slight blockage of the carotid artery be unblocked without surgery (the surgery is know as carotid endarterectomy, or CEA)? I will indeed address that question, and provide some additional information for you so that you can address this issue with your own physician in the near future. Being informed will give you the most value in your future appointments with any physician.

In 2001, the Stroke Council of the American Heart Association came out with a "consensus statement" ... a statement of agreement based upon the study results to-that-date of what to do in instances of carotid artery blockage without symptoms. The statement is that surgery is of greater benefit than no surgery in men without symptoms of blockage, age 40 to 75, with at least 60% blockage of the carotid artery and no other major medical conditions or major blockages on the other carotid artery. I am paraphrasing a great deal, because the consensus statement is lengthy, but this is the essence of it.

Now, to answer your question. YES. We can perform carotid balloon angioplasty and also place carotid stents (little wire tubes that hold the carotid artery open). The problem here is that the outcomes of the studies to-date are very conflicting, and it appears that the CEA Surgery remains the recommended choice for men fitting the criteria for the Stroke Council of the American Heart Association Consensus Statement.

So, at this time, I cannot recommend to my patients with asymptomatic (no symptoms of blockage) blockage of the carotid arteries greater than 60%, that they undergo angioplasty or stent placement. Carotid endarterectomy is still the preferred choice in most people, especially otherwise healthy men, with greater than 60% or greater blockage of a carotid artery. Their long term benefit over a period of years is much greater than those who do not undergo the CEA surgery.

Let me know if you have further questions or concerns.

Thank you for visiting JustAnswer.com's Health Information. I hope that all of your concerns have been addressed and that your experience here was positive and helpful. If you have a new or different question, please don't hesitate to come back or submit a new question. It has been a pleasure helping you. Your FEEDBACK is very important to me.

Customer: replied 6 years ago.
I'm actually a woman. Do the guidelines apply to women?
Expert:  Daniel Nelson, MD replied 6 years ago.

In women the results of surgery are not clearly beneficial, and we generally recommend medical management for women with asymptomatic carotid blockage. This is considered a weak recommendation, based on moderate-quality evidence. One of the problems with the few reliable studies upon which we base these conclusions is that there was not a clear benefit shown for women, and that in another study the risks and benefits for women were not assessed or assessible.

Each person, however, is an individual and their circumstances vary widely. I would have you obtain a report of your Life Line Screening study (it sounds like you already have), and if there is no percentage occlusion listed and it only states "mild-moderate," then it may be of use to get a more definitive study that will show a more defined percentage of occlusion. Carotid angiography is the gold standard. But in the end, we are still left with the fact that the risk versus benefit ratio in women without symptoms is undefined.

I will tell you this, we DO perform carotid surgery on asymptomatic (without symptoms) women, but it is on a case by case basis. The selection criteria are variable, and the input and expectations of the patient are also very important to us. I would recommend discussing this with a physician proficient in CEA surgery, in a major centre where this surgery is performed regularly and with low complication rates of 3% or less for both the institution and the surgeon. One thing to keep in mind, especially if the percentages are higher than 3%, is that this may be due to the fact that the particular surgeon accepts the most severely ill patients at highest risk whereas others may not. So even percentage success and complication alone are not enough to rely upon. I do still recommend a centre and surgeon who perform this procedure regularly if you are considering further evaluation.

Medical management may consist of blood thinner medications like a baby aspirin per day, other anti-platelet medications, and "statins" like Lipitor or Crestor ... the statins help to stabilise atherosclerotic plaques and prevent them from rupturing and causing a stroke, plus, there are other benefits from statins in stoke prevention that we don't yet understand because they effect over 20 steps in the chosterol handling pathways in the body ... but almost all in a good way.

Recommendations:

  • Definitive evaluation of the percentage of occlusion.
  • Evaluation by a physician who specialises in carotid vascular disease, such as Internal Medicine Cardiovascular Diseases (cardiology vascular specialists), Vascular Surgery, Neurosurgery.
  • Discuss medical management versus invasive management once all of your data, including a percentage blockage, as well as thorougth history and physical examination, and risk assessment labs, have been completed.
  • Medicines versus Intervention:
    Aspirin, other anti-platelet medications, "statins" versus CEA Surgery versus Angioplasy versus Stent.

Based on what I have heard so far, it sounds like medical management is the most sound, evidence-based answer. But, because I cannot see you or examine you, plus, I cannot ask all the questions I would like to ask or arrange for certain blood tests or a more definitive assessment of the percentage and location of occlusion, there may be a possibility of recommending intervention. The problem is, there is no consensus for women, yet. The use of stents and angioplasty are not definitive in the medical literature. We need more time and more studies to know for sure whether angioplasty or stenting is superior to, inferior to, or on par with surgery in certain individuals. We need more studies with women who undergo surgery (CEA) and evaluation of risk versus benefit, long term outcomes assessment, and studies that do not contain flaws like several have had.

Regards,
XXXXX XXXXX, MD

Daniel Nelson, MD, Doctor (MD)
Category: Health
Satisfied Customers: 258
Experience: Licensed MD. Mayo Clinic Rochester trained physician in Internal Medicine - Critical Care Medicine.
Daniel Nelson, MD and 5 other Health Specialists are ready to help you
Customer: replied 6 years ago.
I'm having another test in March to see if the condition is stable or progressing. Meanwhile I do take an aspirin a day and I'm on statins for my cholesterol which is around 200 with good LDL and HDL ratios. It's interesting how different the treatments for men and women are.
I live in Durham near Duke University Hospital. I'm sure I can find a very qualified Dr. to help me if need be. Thanks for your help.

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