Carotid Artery Disease

The carotid arteries are the two blood vessels located on either side of the neck that deliver oxygen-rich blood to the brain. There is one carotid artery on each side of the neck and it can be felt with a finger below the jaw bone. When one of these vessels becomes narrowed, bits and pieces of plaque can flow to the brain. A plaque rupture can cause abrupt, complete closure of the carotid artery. This often leads to a stroke (sometimes called a brain attack).

Carotid artery symptoms

If blood flow to part of your brain stops, even very briefly, you may have symptoms of a stroke or “mini-stroke, called transient ischemic attack (TIA.” Seek medical help right away, even if the symptoms last for only a moment. The symptoms you may experience depend on the location of the blocked brain blood vessel.

These symptoms include:
  • Numbness or weakness in your arms or legs, usually on one side only
  • Sudden changes in vision or loss of vision in one eye, often like a window shade being pulled down on one eye
  • Slurring your words
  • A facial droop
  • Difficulty finding words and expressing yourself
These symptoms may last for only minutes, sometimes hours, or they are permanent. Even if you feel back to normal, call 911 immediately. Any of these symptoms may be a sign of a transient ischemic attack (TIA) or stroke. This means the risk for a permanent, devastating stroke is high.

How carotid arteries become blocked

Diseased arteryHigh blood pressure, diabetes, and other health problems, along with smoking and a fatty diet, can cause a fatty substance called plaque to develop. As people age, plaque can build up inside their arteries. Over time, plaque collects on arterial walls. As the plaques builds up, the arteries become narrow and inflexible. This is a process called atherosclerosis, or hardening of the arteries. These narrowed arteries can shed plaque and block blood flow, preventing parts of your brain from getting enough blood and oxygen to work normally.

In addition, plaque buildup makes the artery's walls rough, which can cause blood clots, also called emboli, to form. These clots can break off, travel through the carotid artery, and enter the smaller vessels in your brain. If the clots are large enough, they can block blood flow and cause a stroke. Clots that have traveled into the brain can cause a mini-stroke (TIA) or stroke.

Carotid artery tests

Evaluation for carotid artery disease involves a thorough medical exam. Your doctor will first question you on your complete medical history. Tell your physician about your symptoms. Include any numbness, vision difficulties, or weakness. Also tell your doctor about other health problems that can increase your risk of stroke, such as smoking, high blood pressure or diabetes, and about any health problems exhibited by other members of your family.

After the medical history is complete, your doctor will perform a complete physical evaluation. Some carotid artery blockages can be heard by listening with a stethoscope to the blood flow in your neck. A narrowing in the artery creates a characteristic swooshing sound called a bruit. Your eyes also may be examined (usually by an opthamologist or eye doctor) for tiny spots in their blood vessels. These spots (Hollenhorst plaques) can be a sign of carotid artery problems. Your doctor also may test your reflexes and strength. If your physician hears bruit or suspects a carotid artery blockage because of the symptoms you describe, he or she will order an imaging test to determine whether a blockage is present. This could be an ultrasound test, an angiography or an MRA.

Learn more about the tests, how to prepare and what to expect after the procedure.

Doppler/duplex ultrasound tests

In an ultrasound test, the sonographer or doctor uses sound waves (ultrasound) to make images of your carotid arteries. During the test, a special sensor is gently pressed to the side of your neck. An image of the artery and the blood flowing through it shows how severe the narrowing is.

CT angiography

In a CT angiography, a physician uses a special contrast dye and X-ray images to make a map of your carotid artery. During this test, you lie in a scanner while a contrast dye is injected into a vein in your arm. The scanner then takes detailed pictures of the arteries.

Other imaging tests

A magnetic resonance angiography (MRA) makes an image of your carotid artery without using X-rays. Brain imaging tests can show damage from a past stroke. Any of these tests will provide your physician with the information to determine the severity of the narrowing.

Carotid artery treatment options

If you have carotid artery disease, your physician will likely talk to you about ways to prevent the progression of the disease. One of the most important treatments for carotid artery disease is the prevention of further narrowing or hardening of the arteries. Many of these preventive treatments include lifestyle changes. During your medical evaluation, you and your physician will discuss lifestyle changes that will prevent the worsening of carotid artery blockages. Some methods to prevent worsening blockages include:
  • Treating high blood pressure (hypertension)
    Evidence supports that high blood pressure leads to cholesterol deposits in the carotid arteries, which directly correlates to a greater chance of stroke. If your blood pressure is high, your doctor will choose one of many blood pressure-lowering medications to treat your hypertension and, if needed, discuss methods to lose weight or incorporate exercise into your treatment program.
  • Quitting smoking
    Smoking damages blood vessels and causes cholesterol deposits to form. In order to prevent blockages from worsening, smokers must stop. Longtime smokers, take heart — the high risk of stroke observed among smokers returns to that of nonsmokers within 5 years of quitting.
  • Treating diabetes
    If you have diabetes, your risk for carotid disease and stroke is 4 times higher. You are also likely to have high blood pressure and high cholesterol.
  • Treating high cholesterol
    Because cholesterol deposits lead to plaque buildup on the artery walls, your physician will recommend treatments to lower your cholesterol levels. Changing your diet, losing weight, and exercising are some important ways to control your cholesterol level. If narrowing is already present, you may also be prescribed a statin, which is a cholesterol-lowering medication.
  • Blood thinners
    Blood thinners are part of a class of medicines called anticoagulant. Blood thinners do not really thin your blood. Instead, they block the function of platelets and reduce the ability of platelets to stick together and form a clot. Aspirin, clopidogrel and aggrenox are examples of anti-platelet blood thinners.

Carotid endarterectomy

Carotid endarterectomy is a surgery to reopen a narrowed carotid artery. If you’ve had symptoms of a stroke, you may need surgery right away. If you haven’t had symptoms, your physician may watch your problem over several months before deciding to operate.

If surgery is needed, you’ll have a carotid endarterectomy. The surgery removes plaque, reopening and smoothing your carotid artery. This reduces the chance of clots forming. Even if you don’t need surgery, your physician may suggest lifestyle changes. Controlling blood pressure, quitting smoking, eating healthier, and exercising regularly can help reduce your risk of stroke. You also may be given medication to help improve your blood flow.

Preparing for surgery

You have a role to play in making carotid endarterectomy a success. Be sure to prepare for surgery as directed. Your doctor will tell you what you need to do. He or she also will explain the main risks and complications of surgery. Remember to ask about anything you don’t understand.

Risks and complications

Like any surgery, carotid endarterectomy has certain risks and complications. Some of these risks include:
  • Bleeding
  • Temporary trouble speaking or swallowing
  • Heart attack
  • Stroke
The incision

A skin incision is made near one of the carotid arteries in your neck. The location of the narrowed carotid artery and angle of incision aren’t always the same. Next, an incision is made in the artery itself.

Rerouting blood flow

Your blood may be rerouted for a short time with a shunt (small tube). The shunt allows blood to flow to your brain while your physician works on your artery. If blood flow is strong in your other carotid artery, you may not need a shunt.

Removing plaque

The surgeon carefully loosens plaque from the artery wall. The plaque is then removed. With the plaque gone, the chance of clots forming is greatly reduced.

Closing up

If you had a shunt, it is removed. Your physician then closes the artery with stitches. Next, the skin incision is closed. A small tube may be placed in the incision to help with any drainage that may occur. A small bandage will cover the incision.

Recovering from the procedure

Learn what to expect when you leave the hospital.

Carotid angioplasty and stenting

For some patients, carotid endarterectomy may be considered too risky because of the location of the narrowing, or the patient's health. People with severe heart or lung disease, those who have had neck operations or radiation for neck tumors and those who have already had carotid endarterectomies may not be good candidates for carotid endarterectomy. In those cases, carotid angioplasty and stenting may be a better alternative. Carotid angioplasty and stenting is not the best first choice for treating carotid disease, but is an excellent alternative for those who shouldn’t have surgery.

Carotid angioplasty is relatively straightforward and minimally invasive. A catheter is inserted in the groin artery. It is then threaded through the arteries to the narrowed carotid artery. A tiny balloon at the end of the catheter is inflated to open the narrowed area. Once the area is widened, a slender metal tube, called a stent, is inserted. The stent expands inside the carotid artery to increase blood flow.