Sample Consultation for Carotid Artery Stenosis

The following hypothetical consultation about surgery for carotid artery stenosis is presented for purposes of general information. Please see your doctor to discuss your individual case and the exams and treatments that are best for you.

Background
The following consultation about carotid artery stenosis could apply to any adult. The condition is most common in older adults and can result from atherosclerosis, which is hardening and narrowing of the arteries due to the buildup of plaque.

Consultation

Doctor:   Good morning. What can I do for you today?

Patient: I’m here because my primary care physician was listening to my neck and said he heard sound in it and said I should come see you.

Doctor: He probably heard something that we call a “bruit.”  That is essentially just a sign that you have some turbulent flow in the artery, and it may tell us that you have significant narrowing of the artery. The reason that your doctor sent you would be that there are things that we can do to relieve that blockage in order to prevent future problems that can occur, such as stroke. 

Patient: What other symptoms might I have from this blockage?

Doctor: If you do have symptoms, you might have something that is called a “TIA.” That is essentially a mini-stroke. Typically people may describe episodes where their arm or their leg becomes transiently weak or even paralyzed and then it returns to normal. There may be times when you or a family member may have noticed a droop of your face on one side or the other. You may have trouble speaking or expressing words even though you are completely conscious. Occasionally you may even have trouble understanding what someone else is saying to you. There is one other symptom that is quite common, which is where you may see in one eye, like a window shade coming down, and then it resolves completely. 

Patient: Sometimes for no obvious reason I just sort of feel dizzy for a little bit. Could this be from that as well?

Doctor: It is doubtful. Most of the time, a blockage of your carotid artery shouldn’t cause dizziness in and of itself.  However, the carotid blockage is a manifestation of blockages all throughout the body, which we refer to as atherosclerosis or plaque buildup. So there are other arteries, such as the vertebral arteries which are in back of the head, that may be also affected. In combination with carotid blockage, that could account for your symptoms, but rarely is that the case.

Patient: My doctor was quite concerned about this and he ordered an ultrasound, which I had done. I don’t really understand that test and I know that he sent you the results. I was curious what it was and what was found.

Doctor: Your ultrasound report shows what we would call a moderate to severe degree of narrowing in your right carotid artery. The ultrasound exam looks at flow through that artery and it also looks at the plaque in the artery. Then, based on a combination of how much plaque there is and how much that flow is altered, we make an estimate of how much narrowing there is. The reason that this is important is that the higher the degree of narrowing, with or without symptoms, the more important it is for you to have that obstruction relieved to prevent future episodes of stroke.

Patient: You seem to be talking as if I need an operation. 

Doctor: Based on the narrowing that is seen on your ultrasound, I would recommend an operation.  It is not imperative, but all of the studies show pretty clearly that if you have a good surgeon, the risk of stroke after an operation is much lower than the risk of stroke with carotid artery narrowing that is treated medically. I would recommend an operation. 

Patient: Do I have alternatives?

Doctor: The alternatives include medical treatment, which is essentially using aspirin or any of the aspirin-like agents which would prevent clotting or reduce the risk of clotting. And of course, lifestyle modification such as controlling high blood pressure, better control of diabetes if you have diabetes, stop smoking if you are a smoker. These are things you could do with or without surgery that certainly are important. 

The other alternative treatment is carotid stenting. Carotid stenting is being used more and more.  However, the clinical trials that need to be performed in order to justify it as a true alternative to carotid endarterectomy are still in progress. Carotid stenting has been approved for certain high-risk patients, and there are a variety of reasons that a patient may be considered high risk. However, for the standard patient who is asymptomatic, or even symptomatic, who can undergo carotid endarterectomy, that is still considered the gold standard. If you have a very bad heart or very bad lungs or for some reason are deemed to be at high risk to undergo carotid endarterectomy, then carotid stenting may be a viable option, and we are able to provide that therapy as well. The current data indicate that the older you get, the higher your risk of stroke with carotid stenting, so that is not something I recommend for patients who are aged 70 years or older, but that may evolve in the future.

Patient: Can you tell me a little bit about the surgery?

Doctor: The operation is called a carotid endarterectomy. We make an incision along the front of your neck on the side of the affected artery. We stop the flow through the artery using clamps, and we open up the artery and shell out the plaque that is obstructing the flow. While we are doing this, obviously, you need to have blood flow to your brain, and the other arteries throughout your neck provide that flow in the great majority of patients. During the operation, about 10 percent of patients may need what is called a shunt, which is a way of providing blood flow at those clamps so that the brain is getting enough blood flow while we are cleaning out the plaque. Then, if everything goes well, you are usually in the hospital for a day and you go home the next day, unless there are other issues that keep you longer.

Patient: When can I return to normal life? And when can I return to work?

Doctor: The recovery from this operation is quite quick. You can go about your daily business the following day. The one thing that we ask you not to do is drive for two weeks because the neck incision needs to heal.  Some people may experience some pain, but most people don’t. It is still safer to avoid driving. Other than that, you can resume your other normal activities certainly a week or so later.

Patient: Are there complications?

Doctor: Yes, there can be complications and risk of having complications is directly related to the competence of the surgeon, so your choice of surgeon is very important. You should be sure that the surgeon is someone who has done this operation many times before. The major risk of the operation is the risk of stroke from the operation itself.  The national statistics show that the risk should be no higher than 2 to 3 percent. 

Patient: Are you telling me that I have a 2 to 3 percent chance of having a stroke from having the surgery?

Doctor: No, it is true that there is a risk that you might have a stroke. The national statistics say that if you have 100 patients undergo this operation, 2 or 3 of them may end up with a stroke. What your individual risk is, nobody can really say. These numbers are based on what the risk is for other people like you.

Patient: Are there other risks?

Doctor: The other risk is that there are many vital structures in the neck, some of which are nerves, which can be injured during the operation. If they do get injured, you may have symptoms such as voice changes, hoarseness or difficulty swallowing.  Most of the time, if these symptoms do occur, they are short term and will return to normal within a matter of weeks. But sometimes they can become permanent. 

Patient: What about anesthesia? Do you use a general anesthetic?

Doctor: Yes, and that is the other major risk. Any time a person undergoes an anesthetic, it is possible that the patient will have a heart attack or abnormal rhythms of the heart. It doesn’t happen very often and we always make sure that the heart is in as good a condition as it can be before a patient undergoes an operation. Those are the major risks of this surgery.

Patient: It sounds to me like I should get this done. How do I schedule it?

Doctor:  If you tell me that you are ready to go ahead and have this done, my office will arrange for a time in the operating room and they’ll give you a call.  At your convenience we can go ahead and schedule. 

Patient:   Thank you.

Resources

Learn more at Vascular and Endovascular Surgery and the Sulpizio Cardivascular Center at UC San Diego Health System.