Strokes
A stroke is a devastating problem for the individual, for the family, and for society. A massive stroke may result in death or severe disability. Many survivors of stroke lose the ability to live independently and must be cared for by capable family members and friends. The less fortunate may require services only available through institutionalized care. Loss of independence is frequently complicated by depression, feelings of helplessness, despair, and a loss of the will to live. There are few effective treatments for stroke, and thus strategies to prevent stroke have been encouraged.

The majority of strokes result from atherosclerosis or “hardening of the arteries.” In particular, atherosclerotic plaque in the carotid arteries in the neck may be responsible for up to 60% of the nearly 200,000 strokes that occur annually in the United States. Atherosclerosis results in the accumulation of debris composed of platelets, lipid, cholesterol, scar tissue, calcium, and other cellular components. This debris may fragment and travel as particles into the blood vessels supplying the brain. Obstruction of the blood flow to the brain results in temporary or permanent brain injury, or “stroke.”

Traditional Procedure: Carotid Endarterectomy
Carotid endarterectomy is a surgical procedure that is recognized as the standard of care for prevention of stroke by removal of atherosclerotic debris from the carotid artery in the neck. The procedure requires an incision in the skin of the neck and takes 1-2 hours to perform under either local or general anesthesia. Most patients are discharged the next day and have a very low risk of future strokes.

New Alternative Procedure: Stenting and Angioplasty
A less invasive method of treating blockage in the carotid arteries involves the use of angioplasty balloons and stents. Angioplasty and stenting have been used in the carotid arteries for several years, but recent technological advances have led to wider acceptance of the procedure as an alternative to carotid endarterectomy, particularly in patients with strong reasons to avoid conventional surgery. These so-called “high risk” patients may be unsuited for conventional surgery due to other illnesses such as severe lung or heart disease. In addition, some patients have anatomical reasons that argue against conventional surgery, such as previous neck radiation for cancer or prior neck surgery that may obscure normal anatomic landmarks.

Figure 1 before procedure	Figure 2 after stenting	Figure 3 after balloon angioplasty
Figure 1. This is an arteriogram of the right internal carotid artery. There is a 70% stenosis at the site of a prior carotid endarterectomy. Figure 2. After stent placement, there is a moderate residual stenosis in the center of the lesion. This will be dilated with a 4.5 mm balloon to relieve the stenosis. Figure 3. Final result after stent placement and balloon angioplasty. There is still a very mild residual stenosis of approximately 10% that usually improves with continued outward expansion of the Nitinol stent.

We have initiated a program of carotid angioplasty and stenting in selected patients with reasons to avoid conventional surgery. We assess a variety of medical, anatomic, and physiological factors to develop a specific treatment plan for each patient. In some cases, we may recommend further medical management with careful non-invasive monitoring. In other cases, carotid endarterectomy may be appropriate to reduce the overall risk of stroke. And in select patients, carotid angioplasty and stenting may be recommended as the best treatment alternative.

The following case illustrates the principals that we apply in prevention of stroke due to carotid artery disease. A 65-year-old man was referred for evaluation of a recent episode of transient blindness in the right eye lasting about 15 minutes. He said that it seemed as though a shade had been pulled down over his eye. He had a history of prior carotid endarterectomy six years previously, and he had significant cardiac disease. Based on the fact that he had already had neck surgery and that his heart was damaged from previous heart attacks, we recommended carotid angioplasty and stenting. He underwent successful angioplasty and stenting of the right internal carotid artery and was discharged the same day.

Currently, we are using the Boston Scientific Filterwire to prevent any atherosclerotic debris from traveling to the brain during the procedure. We believe that cerebral protection devices are an important part of our approach to carotid angioplasty and stenting that increases the efficacy and safety of the procedure. We recommend that patients take Clopidogrel, a potent antiplatelet agent, for three months after the procedure.

We have treated more than two dozen patients with this technique during the past twelve months. The recent availability of improved devices and imaging systems has lead to an increased reliance on carotid angioplasty and stenting in our patients. It is predicted that carotid angioplasty and stenting will be selected as an alternative to carotid endarterectomy with increasing frequency in the future.

Patients at higher risk from carotid endarterectomy:

Medical Conditions

• Recent myocardial infarction (MI) < 3 months
• Congestive heart failure with ejection fraction less than 30%
• Severe lung disease with FEV1 < 1l
• Steroid dependent lung disease

Anatomical Conditions

• High carotid bifurcation (above C2)
• Contra lateral carotid occlusion
• Tracheostomy
• Ipsilateral neck irradiation
• Radical neck dissection
• Prior carotid endarterectomy

Patients at higher risk from carotid stenting and angioplasty:

• Severe tortuosity of aortic arch, innominate artery, common carotid artery, or iliofemoral access
• Symptomatic lesions vs. asymptomatic
• Homogenous (soft) plaque by ultrasound
• High grade, long plaque
• Fresh, pedunculated thrombus

Physicians
John F. Eidt M.D., FACS, performs radiofrequency ablations at UAMS. Dr. Eidt attended the University of Notre Dame prior to entering medical school at the University of Texas Southwestern. He completed a General Surgery residency at the Brigham and Women’s Hospital in Boston. He obtained additional training in Vascular Surgery at the University Hospital of South Manchester in England and completed a Vascular Surgery Residency at Southwestern in Dallas. He had special training in Endovascular Surgery at the Cleveland Clinic in 2001 and currently heads the Division of Vascular Surgery at UAMS. Dr Eidt is the medical director of the Vascular Laboratory at UAMS and Program Director of the Vascular Surgery Residency. The UAMS Radiology faculty information page contains further information about Dr. Eidt.

Dr. Eren Erdem, a neuroradiologist, and Dr. Tim McCowan, an interventional radiologist, also perform radiofrequency ablations at UAMS.

Return to Clinical Expertise