Carotid artery disease is a type of peripheral arterial disease in which there is “hardening of the arteries” (atherosclerosis) in the carotid arteries. These arteries, which lie in the neck, carry oxygen-rich blood to the brain. When an individual develops this condition, these vital arteries can become narrowed or blocked by a buildup of plaque along the walls.

People with carotid artery disease are at increased risk of having an ischemic stroke, the most common type of stroke. During this kind of stroke, the blood supply to the brain is obstructed, thus depriving the brain of oxygen-rich blood.

Carotid artery disease may not cause any noticeable symptoms in the early stages. However, as the arteries become narrower, an individual may experience symptoms indicating impaired blood flow to the brain, such as numbness or weakness on one side of the body, difficulty speaking or vision problems. These symptoms can vary in length and could be an indication of a transient ischemic attack (TIA) or stroke.

The disease is usually diagnosed during an individual’s routine physical examination. Based on the patient’s symptoms, the physician listens to the carotid arteries through a stethoscope to determine if any telltale sounds (bruits) are present. Other tests that may be ordered include a carotid doppler ultrasound, magnetic resonance angiogram (a type of MRI), CAT scan and/or a carotid angiogram.

Once a diagnosis has been made, patients are generally urged to make lifestyle changes such as a eating a healthier diet, quitting smoking and getting regular exercise. Under supervision of a physician, a daily dose of aspirin (81 to 325 milligrams), or other antiplatelet or anticoagulant drugs, may be prescribed to reduce the risk of stroke by helping to prevent blood clots. Statins, which are used to lower cholesterol, also may be used to help prevent stroke.

For patients with more serious carotid artery disease, surgery (carotid endarterectomy) or less-invasive procedures, such as carotid artery stenting, may be recommended. During endarterectomy, the surgeon opens the arteries and strips away plaque that is clogging the vessel. During carotid artery stenting, a special metal mesh tube called a stent is permanently implanted in the vessel to help keep it open and reduce the chance of stroke.

Carotid artery disease is a type of peripheral arterial disease in which there is “hardening of the arteries” (atherosclerosis) in the main arteries carrying oxygen-rich blood to the brain (the carotid arteries). These arteries are found on either side of the neck, extending from the aorta to the brain. During atherosclerosis, the inside of the artery is gradually narrowed with a buildup of fatty plaque. As this plaque becomes more severe, there is a chance pieces may break off and travel further downstream in the artery.

If the pieces of plaque become stuck in an artery and obstruct the flow of oxygen-rich blood, the person can suffer a stroke (an ischemic stroke). This is caused by a severe lack of oxygen reaching the brain (cerebral ischemia). Ischemic strokes are the most common form of stroke in the United States.

The risk factors for carotid artery disease are similar to those for coronary artery disease - atherosclerosis of the main arteries carrying oxygen-rich blood to the heart (the coronary arteries). Therefore, people with one condition often have other cardiovascular problems. risk factors for both (as shown by a coronary risk profile) that can be modified include the following:

Risk factors that cannot be modified include the following:

• Gender. Men and women face different risks. For example, women are more likely to both have a stroke and die from a stroke, according to the American Heart Association (AHA).
  
  
• Advanced age. Cardiovascular diseases, as well as peripheral arterial disease, tend to affect older people more than younger people. 
  
  
• Ethnicity. Members of certain groups, such as black Americans, have a higher statistical risk for high blood pressure, which, in turn, is a risk factor for both stroke and heart attack
  
  
• A family history of carotid artery disease or coronary artery disease.

Carotid artery disease typically has no symptoms, making it difficult to diagnose. However, many times, a transient ischemic attack (TIA) is a sign of carotid artery disease. Often called “mini strokes,” TIAs are considered warning signs of a future stroke. They can occur when small pieces of plaque temporarily interrupt the flow of oxygen-rich blood to the brain. Symptoms of a TIA include:

TIAs may also cause a variety of visual symptoms that include:

• Partial loss of vision or complete blindness
• Double vision
• Abnormal eye movement
• Blurred vision
• A gray shading or fogging within the field of vision

People who have experienced these symptoms are urged to see a physician immediately to determine whether they had a TIA and whether they have carotid artery disease. An estimated 20 to 25 percent of TIA patients will develop a stroke within the next two years, and research has shown that 11 percent of patients who have a TIA diagnosed in the emergency room will suffer a stroke in the next 90 days.

Because carotid artery disease usually has no symptoms, it can be a difficult disease to diagnose. In many cases, physicians may persue a diagnosis of carotid artery disease based on the number of risk factors a patient has. One leading risk factor is a family history of coronary artery disease or peripheral arterial disease. Thus, most physicians will begin the diagnosis by taking a complete medical history.

The physician will also ask questions about the patient’s smoking history and level of exercise, as well as other risk factors associated with carotid artery disease. Finally, the physician will ask if the patient has had any recent symptoms of a transient ischemic attack (TIA) or stroke.

Following the medical history, the physician will give the patient a complete physical examination. As part of this exam, the physician will listen to the patient’s carotid arteries through a stethoscope placed on the patient’s neck. Carotid artery disease will sometimes produce sounds called bruits (broo–EEZ), which is the French word for “noises.” However, different physicians interpret these sounds differently, and the sounds are not always present in patients with carotid artery disease. Therefore, a number of tests may be needed in order to make a diagnosis. These tests include the following:

Advanced imaging techniques are also allowing physicians to better describe the characteristics of carotid plaque. For example, many researchers classify plaque as homogeneous or heterogeneous. Homogeneous plaque has a smooth surface and is basically the same texture throughout. Heterogeneous plaque has an irregular surface with areas of hemorrhage. Studies have found that heterogeneous plaque is the likely culprit among individuals who have had a stroke or TIA.

It is felt that therapy for carotid artery disease will eventually be influenced by such characteristics of carotid plaque, in addition to the degree of narrowing (stenosis) of the carotid artery.

Treatment for carotid artery disease depends on the severity of the blockage in the blood vessel. Over time, physicians have developed standards to help them choose between treatment with medication, surgery or a less-invasive procedure. In general, patients may be treated with medication and no surgical intervention if:

For people in these categories, the first step in their treatment will likely begin with controlling risk factors. The controllable risk factors for carotid artery disease are similar to those for coronary artery disease, and the lifestyle changes are the same for both conditions. These include:

• Quitting smoking. Smoking is a major cause of coronary artery disease and cardiac arrest. Heart disease is the leading smoking-related cause of death in the United States among men and women, according to the U.S. Centers for Disease Control and Prevention (CDC). The CDC also suggests that the average smoker dies nearly seven years before a nonsmoker.
  
  
• Maintaining a regular program of exercise. The increased risk from not exercising has been compared to the risk from smoking a pack of cigarettes per day.
  
  
• Reducing cholesterol levels. A key strategy for reducing cholesterol levels is to eat a heart-healthy diet that includes reducing intake of certain fats and oils. Saturated fats increase cholesterol levels. In addition to making diet changes, people are encouraged to exercise regularly. If these strategies do not reduce cholesterol levels, a physician may prescribe cholesterol-reducing drugs.
  
  
• Controlling diabetes. Persons with diabetes may be more likely to develop heart-related diseases. Preventive care is crucial to the overall health and heart function of diabetic patients.
  
  
• Controlling high blood pressure (hypertension). Individuals with high blood pressure are at greater risk of cardiovascular problems resulting from coronary artery disease. High blood pressure is also the most common risk factor for stroke. This is because a buildup of plaque in the arteries can lead to an even greater increase in blood pressure in the damaged areas of those arteries. Hypertension can be controlled through taking blood pressure medications (antihypertensives), eating a heart-healthy, low-salt diet and engaging in regular exercise. People are also encouraged to self-monitor their blood pressure and have regular check-ups with their physician.
  
  
• Learning and practicing stress management techniques. Stress can lead to high-risk situations such as overeating, smoking, high blood pressure and a lack of exercise. In addition, chronic stress may be a direct contributor to poor heart health because it produces increases in blood pressure that could become permanent.

In addition to making lifestyle changes, medications may be prescribed to reduce the risk of stroke. These medications include a daily dose (usually 81 to 325 milligrams) of aspirin or other antiplatelet or anticoagulant drugs to help prevent the formation of blood clots. 

Research has also shown that statins, which are used to lower cholesterol levels, can help prevent stroke. Although their mechanism of action is not completely understood, researchers believe that statins offer some protection through their ability to stabilize plaque deposits, reduce inflammation and slow the progression of carotid arterial disease. Another class of drugs called ACE inhibitors has also been shown to reduce the risk of stroke and heart attack in high-risk patients. Individuals should always consult with their physician before taking any medication or supplement, including  those available over-the-counter.

If lifestyle changes and/or medication are not enough to treat the disease, physicians may recommend either surgery (carotid endarterectomy) or a less-invasive procedure such as angioplasty and stenting. The type of treatment recommended depends on a variety of factors. During a carotid endarterectomy, the patient is usually put under general anesthesia while surgery on the arteries in the neck is performed. Blood flow is temporarily re-routed through a tube and around the blockage in the carotid artery. The obstructing plaque along the wall of the artery is removed resulting in an open artery for maximum blood flow. The tube is removed, and the surgery is complete.

Although research consistently supports the use of an endarterectomy to reduce the risk of having a stroke, the surgery itself carries a risk of stroke and other possible complications. Patients are encouraged discuss the benefits and risks of this procedure with their physicians before undergoing an endarterectomy.

Some patients may also be candidates for a less-invasive procedure known as carotid artery (or angioplasty) stenting. The U.S. Food and Drug Administration (FDA) approved this procedure for use among certain patients in 2004. During this procedure, a catheter is inserted into a blood vessel (usually the femoral artery in the groin) and fed all the way up to the blocked carotid artery. A balloon at the tip of the catheter is then briefly inflated, which presses plaque back against the wall of the artery and makes more room for the blood to flow. Immediately after the balloon angioplasty, a wire mesh metal tube stent is inserted through the catheter and into the artery, where it expands to hold open the artery. A stent becomes a permanent part of the artery’s tissue in a matter of months. The long-term effects of this procedure are still being studied but it is a good alternative for patients who are not good candidates for endarterectomy.

Like endarterectomy, there is a risk that pieces of plaque will break off during the procedure itself and possibly cause a stroke. To prevent this, carotid artery stent systems are designed with special baskets that are temporarily deployed in the blood vessel during the procedure. These baskets are designed to catch any tiny particles of plaque that may break off during the procedure. Research has shown that carotid artery stenting has roughly the same rate of complications as endarterectomy, and may be safer than surgery in high risk patients. .

It  is unclear  if surgery or stenting is better for patients with carotid artery disease. There have been three well-designed trials comparing the two treatments. The first showed that stenting was better for patients who have high risk features - typically severe heart or lung disease. The second trial found that surgery and stenting had similar results in patients who did not have high risk features and the third found that surgery was more effective than stenting in patients who did not have high risk features. Larger trials are ongoing.

The strategies for preventing carotid artery disease include the same lifestyle changes recommended in the treatment of the disease. For patients at high risk of developing the disease, physicians may perform carotid duplex imaging (Doppler ultrasound of the carotid arteries) as part of the patients’ regular examinations to screen for the disease.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctors the following questions related to carotid artery disease:

1. What warning signs may indicate the presence of carotid artery disease?
   
   
2. What symptoms indicate a medical emergency for carotid artery disease?
   
   
3. Do I have a higher risk for carotid artery disease than most people?
   
   
4. What tests will I be given to diagnose this condition?
   
   
5. Can you determine how much blockage I have in my carotid arteries?
   
   
6. Do I have any other cardiovascular diseases?
   
   
7. Can I be treated with medications?
   
   
8. If I need surgery, which procedure do you recommend?
   
   
9. What are the benefits and risks of this procedure?
   
   
10. How long is the recuperation from surgery?
    
    
11. What are the chances my arteries will become blocked again in the future?
    
    
12. How will my condition be monitored after treatment?
    
    
13. What do you recommend to help me quit smoking?
    
    
14. Can you refer me to specialists that can help me with my diet?
    
    
15. Are my children at greater risk for carotid artery disease?