Vascular Surgeons aka Vein Doctors are highly specialised medical doctors that deal with circulation. Vascular surgeons are qualified general surgeons who have super specialised in vascular surgery. They deal with the high-pressure arteries that bring blood from the heart, the low-pressure veins that take the blood back to the heart and the lymphatics that transport fluid back to the heart. Vascular Specialists manage blood vessels in every part of the body, except the heart and the brain
The basics
There is a carotid artery on each side of your neck that transports oxygen-rich blood from your heart to your brain. The walls of healthy carotid arteries are smooth and elastic.
Carotid artery disease is a condition where the arteries become hardened and narrowed. The blockages are usually caused by a build-up of fatty deposits in the artery walls. These are often referred to as cholesterol plaques, and the medical term is atherosclerosis. A common site for these blockages is where the common carotid artery branches into the external and internal carotid arteries.
Carotid artery disease can affect the flow of blood to the brain in two main ways:
- ) A blood clot can form on the surface of the plaque and suddenly block the already-narrowed artery, depriving a large part of the brain of oxygen (“ischaemic” stroke).
- ) Blood clots and debris from the plaque can break off and travel with the upward blood flow to smaller arteries deep inside the brain and block blood supply there (“embolic” stroke).
The resultant stroke symptoms can be temporary if the blockage resolves rapidly and blood flow is restored, or permanent if the flow is not restored in time to prevent permanent brain damage from sustained lack of oxygen. The condition where stroke symptoms resolve completely within minutes or hours is known as a TIA (transient ischaemic attack) or “mini-stroke”.
What increases the risk of carotid artery disease?
The risks of atherosclerosis are the same no matter where in the body the cholesterol plaques develop, and if you have a history of angina, heart attack, peripheral artery disease, or aortic aneurism, you are at risk of carotid artery disease and strokes too.
The commonest risk factors are:
- Smoking
- Diabetes
- High cholesterol
- High blood pressure
- Obesity
- Increasing age and male gender
What are the symptoms and signs of carotid artery disease?
Carotid artery disease often goes unnoticed until there is a significant blockage which results either in a TIA with no permanent brain damage (in which case you are given an opportunity to actively reduce your chances of a stroke in future), or a full-blown stroke with a permanent disability, or even death.
Sometimes, turbulent flow through a narrowed carotid artery can be detected during a health check by listening with a stethoscope over the neck. The turbulence causes vibrations which make a soft “whooshing” sound in time with the heartbeat. The medical term for this sound is “carotid bruit”.
Signs and symptoms of lack of oxygen to the brain depend on which part of the brain is involved. The following are common:
- Numbness, weakness or paralysis in the arm or leg on one side of the body. If the face is affected, it will seem lob sided with drooping of the eye and mouth.
- Confusion
- Difficulty speaking and walking
- Disturbances of vision
- Headache, nausea and vomiting
Medicines
Together with lifestyle measures, medicines may be prescribed, tailored to your risks e.g. to manage blood pressure, diabetes or high cholesterol. Typically, you will also have to take low-dose aspirin which helps to prevent clots from forming. You will notice when you are on regular aspirin that you will bruise more easily.
Surgical procedures
Consideration for surgery depends on a careful assessment of your individual circumstances, which will allow your surgeon to gauge your future risk for stroke without surgery, and to what extent the proposed procedure will reduce this stroke risk. Factors taken into account include whether you have previously had a TIA or stroke, the degree of blockage in the carotid artery, your age, what other medical conditions you have, and the benefits and risks of each management option.
- Carotid endarterectomy is the preferred surgical option for someone with symptomatic carotid artery disease:
- During this procedure, the carotid artery is accessed by making a cut in the neck, and then a cut along the problem section of the carotid artery. The surgeon opens the artery carefully removes the cholesterol plaques and then sews the artery closed again.
- The surgery carries a small risk of serious complications, such as a stroke.
- This involves accessing the carotid artery usually from the groin. First, a guide wire is threaded up to the carotid artery and beyond the blockage, followed by a catheter, which is used to expand a tiny, meshed metal cylinder (stent) at the exact spot where there is narrowing. The stent is expanded to press firmly against the walls of the artery, to open it up.
- This “keyhole” surgery has a higher risk of stroke immediately afterward, and so is typically only recommended if carotid endarterectomy is not an option and you have a particularly high stroke risk.
How is carotid artery disease diagnosed?
Routine screening when there are no symptoms of coronary artery disease does not result in better overall health outcomes in the general population.
However, selective screening in certain high-risk groups may be recommended, such as those diagnosed with atherosclerotic disease elsewhere (such as the legs or heart), those with certain risk factors and those with a carotid bruit.
In someone with symptoms compatible with a TIA or stroke, the easiest way to check for the carotid disease is with a carotid duplex Doppler ultrasound, where a probe emitting ultrasound waves is pressed against the neck to create images showing the coronary artery blood flow and any blockages. Additional more advanced techniques may be needed, such as an angiogram where a contrast agent, injected into the circulation (usually into a vein in the hand or arm), shows up on a CT or MRI scan, to produce a series of clear images of your arteries. This detail may be required if surgery is being contemplated. Angiograms performed in this way are termed “non-invasive”.
Sometimes an “invasive” method of imaging is necessary, called a cerebral angiogram. In this procedure, a catheter is inserted into the groin artery (usually) and threaded to the coronary artery, where dye is injected. The flow of the dye through the neck and brain is monitored in real time using X-rays. Although this is a very accurate way to pick up coronary artery disease, there is a low risk of serious complications, so the decision to use this method needs careful consideration.
Diagnosis also requires an assessment of the degree to which your carotid arteries are blocked, which is related to your risk of future stroke.
- Minor grade – narrowing of less than 50% of the diameter of the artery
- Moderate grade – narrowing of 50-69% of the artery
- High grade (severe) – narrowing of 70% or more of the artery
What are the treatments for carotid artery disease?
The main treatment focus is stroke prevention.
Lifestyle changes to reduce your stroke risk
- Stop smoking.
- Manage other conditions which add to your risk like diabetes, high blood pressure, being overweight and having high cholesterol.
- Strive to keep up a regular exercise program, together with healthy eating, to achieve and maintain a healthy weight and waistline.
If you are looking for Vascular Surgeons In Cape Town, consider Cape Town Vascular. Led by Dr Martin Forlee and Dr James Tunnicliffe, they offer expertise in all aspects of arterial and venous pathology. As specialist vascular surgeons in Cape Town, Dr Martin Forlee and Dr James Tunnicliffe have expertise in managing vascular disease through traditional open surgery as well as minimally invasive arterial and venous endovascular techniques.