June 11, 2025 • 41 mins
In this episode of MedStar Health DocTalk, host Debra Schindler speaks with Dr. Othman Abdul-Malak, MD, MSC, a vascular expert, to break down the what carotid artery disease is, and how it can lead to stroke, mini-strokes (TIAs), and sudden vision loss. Learn how to recognize early warning signs—like facial droop, arm weakness, or sudden speech problems—and why acting fast can save brain function. Dr. Abdul-Malak also explains:
· The difference between ischemic and embolic strokes
· What amaurosis fugax means
· Why age, heart disease, and cholesterol put you at greater risk
· When NOT to take aspirin
This episode is a must-listen for anyone interested in stroke prevention, vascular health, or caring for aging loved ones. Time is brain. Know the signs. Act fast.
Subscribe for more expert-led episodes.
To make an appointment with Dr. Abdul Malak, call 443-777-1900. If you would like to provide feedback on this podcast or get more information when carotid artery disease or treatment options, send me an to DocTalk@medstar.net
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
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Episode Transcript
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(00:00):
Comprehensive,relevant and insightful conversations
about health and medicine happen here onMedStar Health Doc talk.
These are real conversations withphysician experts from around the largest
healthcare system inthe Maryland DC region.
How many times have weseen it in the movies?
Someone checking a victim's pulse byholding two fingers against their neck.
(00:23):
It's the carotid pulse they'relooking for, but why? Well,
carotid arteries are major vessels thatsupply blood to the head because they're
so large.
They have a detectable pulse longer thanother sites like the wrist when blood
flow is weak and there are two of themcreating a pathway on each side of the
neck for blood to get tothe brain, face and neck.
(00:46):
But what happens if the blood flowingthrough the carotid artery is blocked?
In truth, there aren't always symptomsand the result can be catastrophic.
Today on MedStar Health Doc talk,we're taking a closer look
at carotid artery disease,how it's detected and treated
with vascular surgeon,Dr. Othman Abdul Malak. I'm
your host, Debra Schindler.
(01:08):
Welcome Dr. Abdul Malak.
Thank you, Debra. It'sa pleasure to be here.
Talk about this very important topic.
Carotid artery disease was once describedto me as traffic on the body's highway
that delivers oxygen to the brain.
It could be a roadblock, right?
Is that a good way to describe carotidartery disease? What is it exactly?
The carotid arteries are, I would say,your two major arteries that provide
(01:30):
blood flow to your brain and allow us tocontinue to function in a normal way.
And like any other bloodvessel in the body,
they're susceptible to becoming diseased,which can cause narrowing of the artery
and disruption of this blood flow to thebrain,
either by slowly narrowingover time or narrowing
(01:51):
occurs more suddenly and small piecesof that narrowing can break off and go
deeper into the brain causing potentiallya stroke or other symptoms such as
mini strokes, et cetera.
Does a piece like that have tocome off for a stroke to happen?
There are two major types of stroke.
One type is hypoperfusion or adecreased flow to the brain from the
(02:12):
narrowing, but the more common type ofstroke is an embolic kind of stroke,
meaning that a small piece,sometimes even microscopic,
can break off and go deeper into the braincirculation affecting certain regions
of the brain, which canmanifest itself as a stroke,
such as weakness of the arms of the legs,numbness and paralysis of the extremities,
what we commonly refer to asa facial droop altered speech,
(02:35):
it can affect the vision as the carotidartery supplies blood flow to your eye
and your retina.
So that's one of the more commonsymptoms of carotid artery stenosis or
symptomatic carotid artery stenosis.
Patients will typically describe kindof black curtain coming down over their
eyes, kind of like you're watching theopera and it's the end of the show that's
typically referred to as amaurosis fuac.
(02:57):
So there's a very common thatsometimes patients will describe,
they'll come to our officeand say, I feel okay,
but every once in a while I just get thisblack curtain that comes down over my
eye on the one side and it goesaway after a couple of seconds,
and that's a piece of the plaque breakingoff lodging in that area of the eye
for a little bit and then yourbody will kind of break it down.
(03:19):
But that's one of the first signs thatthere could be a problem in your carotid
arteries.
So when the body breaks that down,does it eliminate it somehow or does it
just still float around and undetected?
So oftentimes what happens is onceit blocks a large enough blood
vessel that it'll cause that symptom,but eventually your body will kind of
break it down a little bit and it'llfilter off into a smaller blood vessel
(03:41):
and you'll get your vision back.
But the main issue would then be totreat the carotid artery in the neck,
which is the source of these smallemboli that go up into your brain causing
these stroke-like symptoms.
What is that exactly? TheMI that's floating around
So when you get hardening ordisease in your carotid arteries,
(04:02):
like other arteries in your body,your body will deposit cholesterol
and other particles within thelayers of your artery causing a plaque
and pieces of that plaque break off andgo into your brain.
Okay, so it's part of thathardening of the arteries?
Correct.
Okay. Who's at risk for this?
So the majority of patients withvascular disease and heart disease are at
(04:24):
risk for this. When we lookat the population in general,
I would say the prevalence of any levelof carotid disease is probably around
21% of the general population.
When we look at the prevalence ofclinically significant carotid artery
stenosis,we're probably looking at something
like around 4% in women in menand two and a half percent in women.
(04:47):
And we see that as the population ages,the prevalence in the age population
is much higher than in the youngerpopulation. So it really is
a disease of progressive age.
Does it differ when we're talkingabout the transient ischemic attack
TIA or mini stroke or bigger stroke,like what you had described before?
(05:08):
Really these are spectrumsof the same disease process.
So transient ischemic attacks arecolloquially referred to as mini strokes.
So these symptoms are the same.
The difference is that the transientischemic attacks are typically caused by
smaller emboli and they don't leavea visible imprint on the brain,
meaning that if you were tohave a weakness of your arm,
(05:30):
typically it would last less thanan hour and you're back to baseline,
completely back to normal. For example,I'm just using an arm as
an example of a symptom,and if we were to get
imaging of your brain,we wouldn't see an imprint of a
stroke on your brain. Meanwhile,a stroke is a slightly larger episode
where there is tangible effect on yourbrain that we can measure with
imaging such as CT or MRI.
(05:50):
But really for all intents and purposes,there are two sides of the same coin.
Well, that's interesting. When youtalk about the imprint on the brain.
Just means that in cases of a stroke,when we get an MRI or
a CT scan of the brain,there are clear areas of your brain
that had decreased blood flow.
And we can see that in cases of amini stroke, more often than not,
(06:11):
almost always the MRI orCT scan or negative for any
permanent damage. So in cases of a stroke,even if the patient comes back to their
baseline, so they have some weakness,they have some slurred speech, they get
treated and they eventually improve,you can more often than not still see the
lingering effects on imaging that thispart of the brain was
affected by the stroke.
(06:34):
When I first started talkingabout carotid artery disease,
I mentioned that sometimes there isn't asymptom and the first sign is a stroke.
What are the typical signs when thereare signs of carotid artery disease?
What might the patient experienceand what's the first step?
Is it always an emergency?
So when we look at carotid arterystenosis and carotid artery disease,
(06:56):
I would say the majority of the patientswho present with that disease present
asymptomatically, meaning itis discovered incidentally,
most of the time they go in for theirannual physical and as part of their
physical exam,the cardiologists or the primary care
physicians who are performing this examwill take a listen to
their carotid arteries.
And what they listen for iswhat we call a carotid brewery,
(07:19):
which indicates that the flow through theartery is there, but maybe not normal.
And that leads to a cascade of testsand imaging to detect whether or not
there's any carotid artery stenosis.
And I would say that the asymptomaticpatients are the majority of the patients
and the minority of the patients arethe ones that present with the typical
(07:40):
signs and symptoms of a strokethat we talked about before,
such as weakness of the arms or the legs,numbness, tingling in the extremities,
facial droop, altered speech,altered mental status,
so sudden onset confusion,loss of consciousness or
impaired vision on the areaon the side of the
artery that is diseased.
(08:01):
So someone doesn't have to be doingsomething incredibly physical or stressful
for this to happen,and they just suddenly recognize that
their face is drooping or their wordsaren't coming out right?
Definitely, yes.
Are they usually aware of it?
So it depends on what the symptom is.
So if the symptom manifests asweakness of the extremities,
then the patient's often aware andthey will kind tell you that, oh,
(08:24):
I suddenly was holding a cup of waterand I lost my strength and sensation and
that dropped, or I was using apen and I lost control of that.
I think the first step should be to call9 1 1 and seek emergency medical care
and present to the ER as fast as possible.
Because while there aredifferent kinds of strokes,
(08:44):
some come from central circulation, heartissues, some are due to the carotid,
the key point is that time is brainand the quicker you're at a center
that's equipped to deal with astroke, the better the outcomes are.
And nine one one you call 9 1 1 andthey're going to know where to go.
They're going to know thecomprehensive stroke centers. Right.
Exactly.
(09:05):
Should you take an aspirin.
If you have it? Does.
That help?
I would say I wouldn't take it immediatelybecause some types of stroke are due
to bleeding. So you could also have ahemorrhagic stroke that's a little bit
outside of the scope of carotid disease,but some strokes and some of these
symptoms could be due to bleeding in thehead. So I would say call 9 1 1,
(09:26):
try to get to a comprehensivestroke center as soon as possible.
And once the first setof imaging is obtained,
that will differentiatebetween a hemorrhagic or
ischemic or lack of blood flowkind of stroke. And in the latter,
which is the ischemic or lackof blood flow kind of stroke,
that's when medicationssuch as aspirin, Plavix,
(09:46):
antiplatelet medications and medicationssuch as thrombolytics or clot
busters as we refer to themcolloquially are useful.
Is there any truth to packing icebehind the neck when a patient who is
suspected to have no truth tothat? No truth to that at all.
I can tell by your face. Okay. Idon't know where I heard that from.
(10:08):
Yeah,I don't know that I've heard that maybe
some of my neurology colleagues mightweigh in on that, but I don't
know that I've heard of that.
Well, that's interestingthat you raised that too.
Should someone get to a vascularsurgeon or a neurosurgeon,
what's most important?
So I think most important is thatyou get a facility where it's a true
(10:29):
comprehensive stroke center where thespecialties all work together in tandem.
Here at our program at FranklinSquare, we work very closely with,
as a vascular surgeon, I work veryclosely with the neurosurgeons,
the neurointerventionalists, theneurologists, the neurointensivists,
and we're all really a team that cometogether and take care of the patient.
(10:51):
And each specialty weighs in with theirarea of expertise and what they can
provide.
And I think that allows for everypatient getting the best possible care
because regardless of what the thingthat is needed the most at the time,
we have the ability toprovide the patient with that.
Absolutely. So a patient comesin a stroke, is suspected,
(11:13):
what's the first thing thathappens? You mentioned the imaging.
Is that the first thing that wouldhappen and what kind of imaging is done?
Correct. So when a patientcomes in emergently,
typically they would obtain a CT scanof the head to rule out a bleed in the
brain. And once that's obtained,they would then perform a CT angiography,
which is a CT scan that'sdedicated to making sure that the
(11:37):
blood vessels of the headand the neck are patent.
And oftentimes they add a CT perfusion,which will allow the radiologist and the
neurologist to evaluate whether or notthere are any perfusion defects or any
parts of the brain that are not gettingenough blood flow.
Are the patients usuallyconscious for that?
It depends on how badtheir presentation is,
but the vast majority of them would be.
(11:58):
So those scans must happen pretty quickly.
Very, very quickly. And thendepending on what that shows,
if there's evidence of an acuteblockage of a large vessel,
then the neurointerventionalists arecalled in to weigh in on whether or not
they need to provide any emergent servicesor whether this is something that can
be dealt with medications. And thenif carotid stenosis is suspected,
(12:21):
then we are called in and we kind of weighin on what the best way to treat this
is based on the patient's anatomy,physiology, and other factors.
So when is it determined that surgerymight be needed and what kind of surgery
options are there?
It looks like a lot of acronyms when itcomes to treatment for carotid artery
disease.
Yeah,so the scenario we were discussing is
the one where someone comes in emergentlyand carotid stenosis is identified
(12:46):
as the reason for the stroke.
So once that is established and thepatient has begun recovering from their
stroke symptoms and is improving atthat point we discuss with the patient,
there are different optionsfor carotid revascularization.
So the goal of the surgery is to alleviatethe narrowing of the carotid artery
(13:07):
and prevent future embolicevents from causing strokes,
meaning preventing that plaque frombreaking off and going off into the brain.
There are three major types ofinterventions that we can offer or carotid
disease. The first one iscarotid endarterectomy.
So carotid endarterectomy is the,I would say the gold standard of
interventions. It is, as layman might say,the traditional open surgical option.
(13:32):
Which means cutting open the neck.
Correct. So this means making an obliqueincision in the neck, not very large,
and identifying the carotid artery,making sure to avoid the nerves
that kind of live in that region.
There are nerves therethat help control speech,
swallowing your tongue movement.
And once the artery is identified,then you, for lack of a better word,
(13:54):
you open up the artery and youkind of scoop the plaque out,
making sure to remove theentirety of the plaque,
making sure that there's going to be agood passage of blood through there with
no further loose segments that couldkind of travel up into the brain.
And then the artery is closedusing what we call a patch.
So it's a piece of prosthetic material.
The reason we use that is that sowe don't artificially widen, sorry,
(14:17):
narrow the artery when we close it. Soyou want it to be nice and open and wide.
So how is this done and stillmaintaining blood flow to the brain?
Because we understand that if the bloodflow stops, the brain stops functioning.
Correct? Correct. So as part ofperforming carotid endarterectomy,
we are monitoring cerebralperfusion throughout the procedure.
(14:38):
So there are a couple ofdifferent ways to do that.
You can monitor cerebral oximetry,you can monitor brain
function with EEGs and otherbrain monitors.
You can do a direct measurement of thepressure in the carotid artery after you
clamp it. And the brain is awonderfully designed organ.
(14:59):
And as we talked before,you have your other side,
presumably we'reoperating on the one side,
but the other side is open andflowing through there, and.
That other side can stillappropriately feed the rest of the.
Correct. So there are importantcollateral circulation pathways.
So collateral circulation isbasically kind of back channels.
(15:21):
Through which, okay, shared.
Blood supplies between thetwo sides of your brain,
and it can also recruit blood from theposterior circulation of your brain as
well. It's a well establishedpathway called the circle of Willis.
Different patients have differentpatency of these pathways.
Some people have a completecircle of Willis, others don't.
So when we are doing acarotid endarterectomy,
(15:42):
we're monitoring someone's brain perfusionthrough one of the many different
ways that we can.
And if we notice during the procedurethat the profusion to the brain is being
affected and that the other side or theposterior circulation cannot compensate
for the interruption in blood flow,then we can place a temporary shunt.
So it's a temporary plastic tube goingfrom the proximal carotid artery to the
(16:06):
distal carotid artery that we canwork around to remove the plaque.
Now, as someone who hasnever seen a carotid artery,
I'm trying to grasp what that would looklike. I'm picturing a drinking straw,
and the narrowing of it might be likethen a coffee stir is that am my way out
of the realm of realityin that description.
So it's kind of similar to if youthink of plumbing in your house,
(16:29):
if you think of a pipe in your house,and sometimes you can have the
buildup of debris inside the pipe,and sometimes you can snake a
drain into the pipe and get thatdebris out, and other times you have
to replace that segment of the pipe.
So that's kind of how I would describe it.
It's like taking a pipe with some debrisin it that's stuck in there and you're
(16:50):
opening up that pipe,scooping up that debris,
making sure there's nothing leftthere to clog up your system.
How do you make sure that the gunk thatyou're scraping out of that pipe doesn't
get caught up in a blood flow andthen move on up into the brain?
So when we interrupt the bloodflow to the brain on that side,
that stops the risk of thatdebris going up into the brain.
(17:11):
No chance of that happening?
Yes. Once we clamp theartery, yes. But before that,
correct, once the arties clamp, therisk is minimized. But before that,
obviously when you'remanipulating the artery,
there's always a chance that a piece ofthat plaque will go up into the brain.
That's one of the majorrisks of the surgery.
It's kind of amazing to me to thinkthat you can actually see the plaque.
(17:31):
Yes.
And actually scoop it outwith plaque. I don't know.
What kind of tool wouldyou scoop it out with?
So you scoop it out using and spatula or afreer elevator. So you develop
a plane behind the plaque,ensure to get it all out. You try
to get it all out in one piece.
How big is that? How big thatcarotid artery is it, like I said,
(17:51):
a drinking straw size.
Bigger? Yeah, so it's probablymost carotid arteries.
We're not talking about amicroscopic vessel though.
No, no. Most carotid arteriesare about a centimeter wide.
And then once it dividesinto your internal carotid,
I would say most internal carotid arteriesare around five to six millimeters.
So it's smaller even thanI thought. Then I think.
(18:12):
Yeah, probably a little bitsmaller than a drink and straw.
So when it gets narrow, it's verynarrow. It's actually really small.
So the trickling, it couldstill trickle through that.
The stenosis we arereferring to the narrowing,
it's actually called stenosis.
When there is a stenosis where thevessel is STS stenotic a slower blood
flow,can that still indicate a stroke or
(18:33):
cause a stroke or as long as it's gettingthrough?
It can. It can,but the majority of the time it's small
pieces of that plaque breaking off andgoing up into the brain.
Okay. Yeah. So it's very importantto get that material out.
So either get it out or place a stentacross it that will prevent or minimize
(18:54):
the risk of those pieces breakingoff and going into the brain.
So the stent will keepthat from falling off.
I thought the stent would justopen it up and widen the artery.
So the stent will widenthe artery to an extent,
but it'll also trap that plaqueand minimize the chance of
any of that breaking off andgoing down into the brain.
So that's the other option.
Carotid artery stenting CAS?
(19:17):
Correct. So there areactually three options.
So the one we discussed earlierwas carotid endarterectomy,
which is kind of moretraditional open surgery.
And then carotid artery stenting wasfor a long time. The other option,
and that involves placing astent in the carotid artery,
most commonly coming fromthe groin or the wrist,
similar as one would come for a lowerextremity angiogram or a heart angiogram
(19:39):
or something like that.
It involves getting across thearea of the narrowing with a wire,
placing a protective filter tocatch any possible debris that
you might agitate from the plaque.
Where is the filter?
The filter's deployed above the lesiononce you cross it with the wire.
And that helps to catch anythingthat might fall off the plaque while
(20:03):
you're putting your stent up.
So it doesn't stay in there.
The filter? No, it doesn't stay in.
It's something that you put up andthen you recapture and bring outside.
And more recently, kind of a hybridtechnique has been innovated.
Proposed is very common now it'scalled the trans carotid arterial
revascularization or TAR for short.
And thistechnique kind of merges components
of open and endovascular surgery.
(20:27):
So it involves making a smallincision at the base of the neck,
so not exactly where you would makea carotid endarterectomy incision.
Through that incision, you find whatwe call the common carotid artery,
which is an area lower down thanwhere the narrowing is that's causing
the problem. And once identify that,then you access that with a needle and
(20:48):
you place your wires and your catheters,and through that, you place a stent.
The benefit of that is that you'reable to control the blood flow up to
the brain in a similar way that youwould in a carotid endarterectomy,
which can drastically minimize the riskof stroke because of the procedure.
(21:08):
So whenever we think of anyprocedure for carotid surgery,
whether it's endarterectomy,carotid artery stenting, or TAR,
one of the things that we talk to patientsabout the most is the risk of stroke
because the procedure itselfcan cause a risk of stroke.
And then the second thing we talk aboutspecifically for carotid endarterectomy
and to some extent trans carotidarterial revascularizations or TAR,
(21:31):
we talk about the risks of nerveinjury. As we talked about,
there are some nerves in the area ofcarotid artery that we have to be very
vigilant for when we are performingopen surgery in this area.
What could happen ifthere is nerve damage?
So if there is nerve damage, sometimesthere's issues with tongue movement.
So one of the nerves is verygro in controlling your tongue,
(21:53):
which can affect speech,which can affect swallowing.
Some of the other nerves directlyinvolve control of your vocal cords,
which can affect the injury.
Some of the nerves can affectthe quality of your voice,
so you can have some hoarseness andsometimes it can cause inability to
properly move your vocal cords, whichcan again affect speech and swallowing.
(22:15):
Sounds like the risks are rather high.
They are, but the rewardis also high as well.
So for a lot of these patients,their risk of recurrent stroke after
the initial episode remains pretty high,even with maximum medical therapy.
So that's why for patients who havehad the documented stroke or TIA,
(22:35):
the risk of intervention is farless than the benefit they gain
from the surgery or stent.
Is that just a fine print or does.
It No. So how often does a stroke happen?
I mean these repercussions such as nervedamage or a stroke is because of the
procedure.
Correct? Yeah. So I would sayit's probably less than 0.5%.
So.
Stroke is maybe 0.5 to 1% andnerve injury is less than 0.5%.
(22:59):
So it's rare, but we talk aboutit because when it does happen,
it can affect thepatient's quality of life.
If it happens on one side ofthe carotid, as we talked about,
it splits off there's two sides,is it likely to also this
stenosis or this narrowing orblockage going to happen the other side?
It definitely could.
(23:19):
When we are following patients in theoffice who have asymptomatic carotid
artery stenosis where we oftenfollow both sides with an ultrasound,
we are obviously very vigilant to makesure that the other side doesn't develop
stenosis.
Or if it does that we stay on top of itand we make sure that if it gets severe,
we're having the appropriatediscussions with the patients.
(23:39):
What are you able tosee with the ultrasound?
Can you actually see anarrowing that's dangerous?
Yeah, so ultrasounds areactually, in my opinion,
one of the best initial tests to getfor carotid artery stenosis for when
patients come into my office.
So if a patient, for example,is referred into my office because of
either an incidental finding that someonenoted on a CT scan or on a physical
(24:00):
exam someone heard abnormalflow in their carotid artery, getting an
ultrasound is vital because number one,it can show you what the artery
looks like on ultrasound,so it can show you areas of plaque and
hardening and narrowing. And secondly,it shows you the P of blood flow
through the area of narrowing,which can give you a very good estimate
(24:21):
as to how severe the narrowing is.
And there's very good data that correlatesthe speed of blood flow through the
narrowing to how severe the narrowingis to when you should consider
interventions in these patients.
These procedures, once they happen.
Now I'm talking about the CAS,the TAR and the CEA,
(24:43):
presumably they're under generalanesthesia and then they spend a night,
two nights. What's thefollow up and recovery?
So it depends. Different people,different proceduralists,
different interventionalistsperform these differently.
I would say for the majority of patients.
For me, carotid endarterectomies,I do under general anesthesia, TAI do
the majority under general anesthesia,however, it's been described that
(25:05):
you do those under sedation as well.
Some people do that as a way ofmonitoring the flow to the brain.
Here at MedStar, the way I do them,as I do endarterectomies in
TA under general anesthesia,when we place a carotid
stent from the groin,typically those patients are done under
a little bit of numbing medication and alittle bit of sedation,
but they're more awake because that'show we monitor blood flow to the brain.
(25:29):
We continually talk to the patient,ask them to say words or squeeze
squeezey toy that makes noise,make sure they can follow commands,
make sure the procedure's going well.
All of these patients spendone night in the hospital.
The goal of that is to make sure thatwe're monitoring them closely afterwards,
making sure there are no issues,no recurrence, stroke symptoms.
(25:51):
We're monitoring their blood pressure.
You want to have very good control ofsomeone's blood pressure after the surgery
to prevent certain complications.
And the majority of the patients,I would say 99% go home the next
morning or the next afternoon.
If they come in with strokesymptoms because of the blockage.
Once that repair is made, is itrevocable, is it recoverable?
(26:13):
So a lot of times when patientscome in with severe stroke symptoms,
we begin the medical treatment andthen we give the patient some time to
start to recover. So more often than not,we are already seeing recovery from
their stroke At the time that we do thisprocedure,
the patients typically tend to continueto improve from their stroke symptoms.
So like the speech you mentioned,the ability to eat or what about
the blindness? The vision issues.
(26:38):
So sometimes that's permanent.
It depends on when theypresent and how they respond to
the medications initially.
But we tend to give themsome time after their stroke
to recover for the brain to showsigns of recovery before we pursue
revascularization of their carotid.
What about rehabilitation?
(26:59):
Of course. Of course. As part of thecomprehensive stroke care that we provide,
you're evaluated by the rehabprofessionals before discharge.
And every patient will have differentneeds depending on their level
of support at home, how wellthey're progressing from the stroke,
how quickly their symptoms are improving.
We talked a little bitabout who is at risk,
(27:20):
but what are some of the other causesfor something like this to happen?
Is it usually, do you findin the family history?
I would say the major risk factors fordeveloping carotid artery disease is the
presence of otherdiseases. So like I said,
it is a disease of advanced age, and wedo see that with every decade in life,
(27:41):
the risk of developing carotidartery disease increases.
Smoking is definitely one ofthe modifiable risk factors,
the presence of any clinicallyevident peripheral arterial disease.
So if someone has evidence of vasculardisease in their legs, their arms,
their heart,that puts them at a higher risk of
also having disease in their carotids.
(28:02):
At the same time, patients withhigh blood pressure, diabetes,
high cholesterol,or all conditions that are associated
with carotid artery stenosis,in addition to the
presence of, like I said,heart disease and
abdominal aortic aneurysms.
If someone who's had a cardiaccatheterization and had stents put in,
should they get an ultrasoundautomatically in their there?
(28:25):
So that's a very good question.
When we think about screeningin the general population,
we think about maximizingthe benefit to the patients.
So we want to screen to preventbad outcomes from happening.
When we look at the data that's availableto screen the general population for
carotid disease,it's not recommended at this moment to
screen the general population for carotiddisease. However,
(28:49):
certain populations are recommendedto be screened for carotid disease,
and those are the patientsthat are at higher risks,
anyone with clinically significantperipheral vascular disease.
So someone who's been diagnosed withclaudication or rest pain in their
extremities,patients who are over 65 with evidence
of heart disease like you mentioned.
So if someone had a heart catheterization,had stents and they're over 65,
(29:12):
they should get a screening carotidultrasound over 65 with heart disease,
smoking and high cholesterol so thatthose three conditions and the age of
65, those patients have abenefit to being screened.
And then patients who have heart diseasethat requires open heart surgery,
those patients should be screened forcarotid disease and are typically screened
as part of the workupfor open heart surgery.
(29:34):
Yeah, I think I would just want tobe screened if I had a cardiac stent.
Because.
Your body wants to producearterio sclerosis or a plaque,
I'd be very nervous about what washappening in my carotid artery.
And I think we see that the majority ofthose people do end up being screened
because when you think aboutthe criteria that I mentioned,
65 with heart disease, smoking and highcholesterol, and more often than not,
(29:58):
patients who have heart disease tendto be smokers or history of smokers and
have high cholesterol.
So a lot of the patients who end uphaving clinically demonstratable heart
disease do end up gettingscreened for their carotids.
And on the flip side,should someone who's had a coronary
artery problem or a blockage stenosisbe screened for cardiac stenosis.
(30:20):
If you have carotid artery disease,more often than not you fulfill the
criteria to get screened for vasculardisease in your other beds.
What role do statins and blood pressuremedications play in managing carotid
artery disease?
Yeah, so carotid artery disease, likea lot of times as a disease process,
we see in outpatientevaluations of patients.
(30:40):
So we discussed the patient that comesin with an acute stroke to the hospital
and how that kind of unfolds,but more often than not,
we see patients with carotidartery stenosis in our offices and
whether they have symptoms orasymptomatic risk factor modification or
medical management is paramountin patients with this condition.
(31:02):
And statins play a vital role inmodulating plaque all over the
body. And the way they work obviously,is by decreasing your
LDL or your cholesterol,your bad cholesterol,
and increasing your HDL,which is your good cholesterol and
controlling your triglycerides,which is kind of the fat
content in your blood.
But other schools of thought aswell indicate that not only do
(31:25):
statins kind of give youa better lipid profile,
which is the numbers that patients whoare on statins check to make sure their
cholesterol is headedin the right direction.
Some studies suggest that statinsthemselves provide stabilization of the
plaques so they can also just makethese plaques or these narrowings less
problematic or less likely tocause an embolization event,
(31:47):
which could cause a mini stroke or astroke. And then blood pressure control
obviously is vital for overall health,minimizing disease progression
and for perioperative managementfor the patients who
qualify to get a procedure.
Now, I did read while researchingthis before we met today,
that there is some debate over thebest approach to treating asymptomatic
(32:11):
patients. So patients maybe who foundthat they had a stenosis or a blockage
incidentally, should they betreated? What's your opinion on that?
Yeah,I think that's a very common
topic of debates in the vascularsurgery world.
The treatment of asymptomaticpatients with carotid artery stenosis,
(32:31):
like we talked about,one of the major risk factors
of the procedure is strokealso trying to do is you're
trying to prevent a stroke.
So the studies that we have available tous that kind of guide the treatment of
carotid disease, whether it's symptomaticor asymptomatic or on the older side,
now they're very good trials, very gooddata, but it's a little bit outdated.
(32:53):
And one of the biggest,I think landmark trials in the carotid
surgery world is ongoing today.
It's looking at stenting versusendarterectomy and symptomatic versus
asymptomatic. So hopefully we'll have amore data-driven answer soon. However,
to your point,a lot of different providers treat
asymptomatic disease differently.
The way I treat asymptomatic diseasepersonally is when I identify a patient
(33:17):
with an asymptomatic stenosisabove 50%, but less than 70,
I tend to discuss medicalmanagement with them, counsel.
And when you say 50%, youmean 50% of it is close, so.
Correct.
So the way we classifynarrowings typically when
office is we classify themas 50 to 69% and greater than
(33:39):
70% less than 100.
And then there are certain features onultrasound that can indicate a higher
than 80% stenosis as well.
And those you would treat.
Yeah.
So when I look at a patient with anasymptomatic carotid artery stenosis of
about 50 to 69%, I would focuswith them on smoking cessation.
If they're smoking,I would recommend nicotine
replacement therapy.
(34:02):
Other therapies recommend them to see asmoking cessation counselor provide them
with all the support that theyneed to go down that path.
The journey of quitting smoking,I would discuss with their primary care
physician to ensure that they're on ahigh dose statin, they're on an aspirin,
that their blood pressureis well controlled, their
(34:23):
and start the medicalrisk factor optimization.
And I would follow them with ultrasoundsin my office at predetermined interval.
So I would see them again in six months,and then I would start
seeing them every year.
That way we can keep an eye on thenarrowing and see if it gets worse. For
patients who have severenarrowings over 80%,
(34:43):
I would have another in-depthconversation with them about the risk of
intervention.
I would discuss with them that you're acandidate for endarterectomy or you're a
candidate for a stent depending ontheir physical fitness, their anatomy,
all that stuff.
And then what I would really wantto make sure is that they're really
(35:04):
in good health because when you lookat the data that exam and treating
asymptomatic carotid stenosis,you really want patients to have a life
expectancy of at least three to fiveyears for them to reap the benefit
of this preventative procedure.
What's the oldest patient that you'vetreated and what's the youngest?
I would say the youngest with theyoungest with a carotid artery problem was
(35:26):
probably in their early fifties.
And it was shocking because I wasactually managing their lower
extremity arterial disease,and I had done a couple
of procedures on them,and they were on the way
to recovering from that,and they called the
office and they were atwork, and they reported that they
(35:47):
needed to speak to the doctor.
I was in clinic, finished up my patient.
I called them back an hour later,and in my mind I was like, there's
going to be a problem with, God forbid,the bypass or the blood
flow to the leg, et cetera.
And I started asking them about theirleg and how the operation was and if
(36:08):
everything's okay, and they'relike, oh yeah, everything's fine.
Everything's fine. I'm just,every couple of minutes,
I just can't see out of my left eyeanymore. Huh. That's interesting.
Have you ever had this lookedat, et cetera. He's like, no,
it's just been happening for about aday and a half straight every couple of
hours. I can't see out of my lefteye though. I gave him a call.
I was on the phone with him. I toldhim, please come to the office today.
(36:32):
I think there might be something goingon in your carotid artery, et cetera.
And they were able to come into theoffice and we did an ultrasound,
which showed very, very severestenosis of their carotid artery.
And we could see on the ultrasoundthat plaque there looked like it may be
unstable. It did not looklike a normal plaque.
(36:52):
So I recommended to him that Iwant to admit you to the hospital,
put you on some blood thinners, get someimaging and fix this. And thankfully,
he was agreeable.
He was able to figure things out atwork and family and childcare and
everything, and we got him acrossthe street to the hospital.
We got him admitted.
I think the next day we ended updoing a carotid endarterectomy.
We got a CT scan, an MRIdidn't show any acute stroke,
(37:15):
and his vision was back to normal.
Good.
So he was classified as havinga TIA and that we talked about
earlier.
Right.
And he underwent a carotidendarterectomy and he did. Well, thank.
Goodness he communicated that with you.
Yeah, I was glad.
Could that damage have been permanent?
It could have for sure. It couldhave. And for him specifically,
(37:39):
he was already on medical therapy forhis lower extremity arterial disease,
so that was even more jarring to me, andthat's why I felt the need to tell him,
you're already on pretty much max doseanti-platelet medications and a blood
thinner, and you're havingthis problem that's ongoing,
so I think this is something weneed to address really quickly.
And he was young, hadyoung kids, and so it was.
(38:01):
Successful.
Thankfully. Yes. Yeah.
Do you see carotid diseasetreatment changing much in
Where are we headed?
Carotid disease and vascular surgery ingeneral is an ever-changing field where
I think that the introduction of transcarotid arti revascularizations or
TAR has been fantasticbecause it's expanded.
(38:23):
The patients that now haveaccess to carotid therapy.
A lot of patients were lost in theshuffle where they didn't have good
anatomy for a stent or were too highrisk to get a stent from the groin
because of their anatomyand the risk of stroke,
but they were too high risk for acarotid endarterectomy because of neck
(38:43):
anatomy or prior surgeriesor radiation, what have you.
And then this hybrid procedure,it's not very new now.
It's been out for a few years,but as it's becoming more and more
adopted and more and more an option forpatients, and more and more
surgeons are facile with it,I think it's been a great
advancement of the field of carotidtreatment,
(39:08):
and I think minimally invasive techniqueswill continue to improve in vascular
surgery as well as in carotid surgery,and I'm excited to see
what's on the horizon.
Do you love what you do?
I do very much, yeah.
Did you always want tobe a vascular surgeon?
I knew I wanted to be a surgeon ata very young age. How old were you?
I was probably 11 or 12 years oldwhen I knew I wanted to be a surgeon,
(39:30):
and I think my fascination withsurgery was such that every
rotation I would go on as a medicalstudent, I would be enthralled by it.
I'd go on orthopedic rotation. Thisis amazing. I do ENT. I'm like,
this is incredible plastic surgery. Wow.
I'm amazed at everything.
And ultimately,I started out in general surgery
because I knew I wanted to be a surgeon,but I just wanted to see more.
(39:55):
Then early in my general surgery training,I did a vascular surgery rotation,
and I was just amazed at what we'reable to do through a remote access
point in the body sincethe wrist or the groin,
and you can treat the toeor the brain, and it's
in the same breadth of one day youcan do an open surgery on someone's
(40:17):
abdomen and then treat their leg througha minimally invasive poke in the groin,
and then the next phone callis about someone's carotid,
and you're dealing with all aspects ofthe body, all different vascular beds,
and it's very rewarding.
What I think I like the most aboutvascular surgery is you still have to be a
doctor in a way. You followa lot of our patients,
(40:37):
we follow them longitudinally.
We develop a very close relationshipwith them, not just as surgeons,
but also as medical doctors working veryclosely with the primary care doctors,
the cardiologists, theendocrinologists, the podiatrists.
You're very much involved in thepatient's long-term longitudinal care,
(40:58):
which is very nice for me as a doctor.
Well, thank you,Dr. Abdul Malak for sharing your expertise
with us here on MedStar Health DocDog. Of course. To make an
appointment with Dr. Abdul Malak,contact 4 4 3 7 7 7 1 900.
That's 4 4 3 7 7 7 1 900.
(41:19):
If you would like to provide feedbackon this podcast or get more information
when carotid artery disease ortreatment options, send me an email,
Debra schindler@medstar.net.
Comprehensive,relevant and insightful conversations
about health and medicine happen here onMedStar Health Doc talk.
These are real conversations withphysician experts from around the largest
healthcare system inthe Maryland DC region.
How many times have weseen it in the movies?
Someone checking a victim's pulse byholding two fingers against their neck.
(00:23):
It's the carotid pulse they'relooking for, but why? Well,
carotid arteries are major vessels thatsupply blood to the head because they're
so large.
They have a detectable pulse longer thanother sites like the wrist when blood
flow is weak and there are two of themcreating a pathway on each side of the
neck for blood to get tothe brain, face and neck.
(00:46):
But what happens if the blood flowingthrough the carotid artery is blocked?
In truth, there aren't always symptomsand the result can be catastrophic.
Today on MedStar Health Doc talk,we're taking a closer look
at carotid artery disease,how it's detected and treated
with vascular surgeon,Dr. Othman Abdul Malak. I'm
your host, Debra Schindler.
(01:08):
Welcome Dr. Abdul Malak.
Thank you, Debra. It'sa pleasure to be here.
Talk about this very important topic.
Carotid artery disease was once describedto me as traffic on the body's highway
that delivers oxygen to the brain.
It could be a roadblock, right?
Is that a good way to describe carotidartery disease? What is it exactly?
The carotid arteries are, I would say,your two major arteries that provide
(01:30):
blood flow to your brain and allow us tocontinue to function in a normal way.
And like any other bloodvessel in the body,
they're susceptible to becoming diseased,which can cause narrowing of the artery
and disruption of this blood flow to thebrain,
either by slowly narrowingover time or narrowing
(01:51):
occurs more suddenly and small piecesof that narrowing can break off and go
deeper into the brain causing potentiallya stroke or other symptoms such as
mini strokes, et cetera.
Does a piece like that have tocome off for a stroke to happen?
There are two major types of stroke.
One type is hypoperfusion or adecreased flow to the brain from the
(02:12):
narrowing, but the more common type ofstroke is an embolic kind of stroke,
meaning that a small piece,sometimes even microscopic,
can break off and go deeper into the braincirculation affecting certain regions
of the brain, which canmanifest itself as a stroke,
such as weakness of the arms of the legs,numbness and paralysis of the extremities,
what we commonly refer to asa facial droop altered speech,
(02:35):
it can affect the vision as the carotidartery supplies blood flow to your eye
and your retina.
So that's one of the more commonsymptoms of carotid artery stenosis or
symptomatic carotid artery stenosis.
Patients will typically describe kindof black curtain coming down over their
eyes, kind of like you're watching theopera and it's the end of the show that's
typically referred to as amaurosis fuac.
(02:57):
So there's a very common thatsometimes patients will describe,
they'll come to our officeand say, I feel okay,
but every once in a while I just get thisblack curtain that comes down over my
eye on the one side and it goesaway after a couple of seconds,
and that's a piece of the plaque breakingoff lodging in that area of the eye
for a little bit and then yourbody will kind of break it down.
(03:19):
But that's one of the first signs thatthere could be a problem in your carotid
arteries.
So when the body breaks that down,does it eliminate it somehow or does it
just still float around and undetected?
So oftentimes what happens is onceit blocks a large enough blood
vessel that it'll cause that symptom,but eventually your body will kind of
break it down a little bit and it'llfilter off into a smaller blood vessel
(03:41):
and you'll get your vision back.
But the main issue would then be totreat the carotid artery in the neck,
which is the source of these smallemboli that go up into your brain causing
these stroke-like symptoms.
What is that exactly? TheMI that's floating around
So when you get hardening ordisease in your carotid arteries,
(04:02):
like other arteries in your body,your body will deposit cholesterol
and other particles within thelayers of your artery causing a plaque
and pieces of that plaque break off andgo into your brain.
Okay, so it's part of thathardening of the arteries?
Correct.
Okay. Who's at risk for this?
So the majority of patients withvascular disease and heart disease are at
(04:24):
risk for this. When we lookat the population in general,
I would say the prevalence of any levelof carotid disease is probably around
21% of the general population.
When we look at the prevalence ofclinically significant carotid artery
stenosis,we're probably looking at something
like around 4% in women in menand two and a half percent in women.
(04:47):
And we see that as the population ages,the prevalence in the age population
is much higher than in the youngerpopulation. So it really is
a disease of progressive age.
Does it differ when we're talkingabout the transient ischemic attack
TIA or mini stroke or bigger stroke,like what you had described before?
(05:08):
Really these are spectrumsof the same disease process.
So transient ischemic attacks arecolloquially referred to as mini strokes.
So these symptoms are the same.
The difference is that the transientischemic attacks are typically caused by
smaller emboli and they don't leavea visible imprint on the brain,
meaning that if you were tohave a weakness of your arm,
(05:30):
typically it would last less thanan hour and you're back to baseline,
completely back to normal. For example,I'm just using an arm as
an example of a symptom,and if we were to get
imaging of your brain,we wouldn't see an imprint of a
stroke on your brain. Meanwhile,a stroke is a slightly larger episode
where there is tangible effect on yourbrain that we can measure with
imaging such as CT or MRI.
(05:50):
But really for all intents and purposes,there are two sides of the same coin.
Well, that's interesting. When youtalk about the imprint on the brain.
Just means that in cases of a stroke,when we get an MRI or
a CT scan of the brain,there are clear areas of your brain
that had decreased blood flow.
And we can see that in cases of amini stroke, more often than not,
(06:11):
almost always the MRI orCT scan or negative for any
permanent damage. So in cases of a stroke,even if the patient comes back to their
baseline, so they have some weakness,they have some slurred speech, they get
treated and they eventually improve,you can more often than not still see the
lingering effects on imaging that thispart of the brain was
affected by the stroke.
(06:34):
When I first started talkingabout carotid artery disease,
I mentioned that sometimes there isn't asymptom and the first sign is a stroke.
What are the typical signs when thereare signs of carotid artery disease?
What might the patient experienceand what's the first step?
Is it always an emergency?
So when we look at carotid arterystenosis and carotid artery disease,
(06:56):
I would say the majority of the patientswho present with that disease present
asymptomatically, meaning itis discovered incidentally,
most of the time they go in for theirannual physical and as part of their
physical exam,the cardiologists or the primary care
physicians who are performing this examwill take a listen to
their carotid arteries.
And what they listen for iswhat we call a carotid brewery,
(07:19):
which indicates that the flow through theartery is there, but maybe not normal.
And that leads to a cascade of testsand imaging to detect whether or not
there's any carotid artery stenosis.
And I would say that the asymptomaticpatients are the majority of the patients
and the minority of the patients arethe ones that present with the typical
(07:40):
signs and symptoms of a strokethat we talked about before,
such as weakness of the arms or the legs,numbness, tingling in the extremities,
facial droop, altered speech,altered mental status,
so sudden onset confusion,loss of consciousness or
impaired vision on the areaon the side of the
artery that is diseased.
(08:01):
So someone doesn't have to be doingsomething incredibly physical or stressful
for this to happen,and they just suddenly recognize that
their face is drooping or their wordsaren't coming out right?
Definitely, yes.
Are they usually aware of it?
So it depends on what the symptom is.
So if the symptom manifests asweakness of the extremities,
then the patient's often aware andthey will kind tell you that, oh,
(08:24):
I suddenly was holding a cup of waterand I lost my strength and sensation and
that dropped, or I was using apen and I lost control of that.
I think the first step should be to call9 1 1 and seek emergency medical care
and present to the ER as fast as possible.
Because while there aredifferent kinds of strokes,
(08:44):
some come from central circulation, heartissues, some are due to the carotid,
the key point is that time is brainand the quicker you're at a center
that's equipped to deal with astroke, the better the outcomes are.
And nine one one you call 9 1 1 andthey're going to know where to go.
They're going to know thecomprehensive stroke centers. Right.
Exactly.
(09:05):
Should you take an aspirin.
If you have it? Does.
That help?
I would say I wouldn't take it immediatelybecause some types of stroke are due
to bleeding. So you could also have ahemorrhagic stroke that's a little bit
outside of the scope of carotid disease,but some strokes and some of these
symptoms could be due to bleeding in thehead. So I would say call 9 1 1,
(09:26):
try to get to a comprehensivestroke center as soon as possible.
And once the first setof imaging is obtained,
that will differentiatebetween a hemorrhagic or
ischemic or lack of blood flowkind of stroke. And in the latter,
which is the ischemic or lackof blood flow kind of stroke,
that's when medicationssuch as aspirin, Plavix,
(09:46):
antiplatelet medications and medicationssuch as thrombolytics or clot
busters as we refer to themcolloquially are useful.
Is there any truth to packing icebehind the neck when a patient who is
suspected to have no truth tothat? No truth to that at all.
I can tell by your face. Okay. Idon't know where I heard that from.
(10:08):
Yeah,I don't know that I've heard that maybe
some of my neurology colleagues mightweigh in on that, but I don't
know that I've heard of that.
Well, that's interestingthat you raised that too.
Should someone get to a vascularsurgeon or a neurosurgeon,
what's most important?
So I think most important is thatyou get a facility where it's a true
(10:29):
comprehensive stroke center where thespecialties all work together in tandem.
Here at our program at FranklinSquare, we work very closely with,
as a vascular surgeon, I work veryclosely with the neurosurgeons,
the neurointerventionalists, theneurologists, the neurointensivists,
and we're all really a team that cometogether and take care of the patient.
(10:51):
And each specialty weighs in with theirarea of expertise and what they can
provide.
And I think that allows for everypatient getting the best possible care
because regardless of what the thingthat is needed the most at the time,
we have the ability toprovide the patient with that.
Absolutely. So a patient comesin a stroke, is suspected,
(11:13):
what's the first thing thathappens? You mentioned the imaging.
Is that the first thing that wouldhappen and what kind of imaging is done?
Correct. So when a patientcomes in emergently,
typically they would obtain a CT scanof the head to rule out a bleed in the
brain. And once that's obtained,they would then perform a CT angiography,
which is a CT scan that'sdedicated to making sure that the
(11:37):
blood vessels of the headand the neck are patent.
And oftentimes they add a CT perfusion,which will allow the radiologist and the
neurologist to evaluate whether or notthere are any perfusion defects or any
parts of the brain that are not gettingenough blood flow.
Are the patients usuallyconscious for that?
It depends on how badtheir presentation is,
but the vast majority of them would be.
(11:58):
So those scans must happen pretty quickly.
Very, very quickly. And thendepending on what that shows,
if there's evidence of an acuteblockage of a large vessel,
then the neurointerventionalists arecalled in to weigh in on whether or not
they need to provide any emergent servicesor whether this is something that can
be dealt with medications. And thenif carotid stenosis is suspected,
(12:21):
then we are called in and we kind of weighin on what the best way to treat this
is based on the patient's anatomy,physiology, and other factors.
So when is it determined that surgerymight be needed and what kind of surgery
options are there?
It looks like a lot of acronyms when itcomes to treatment for carotid artery
disease.
Yeah,so the scenario we were discussing is
the one where someone comes in emergentlyand carotid stenosis is identified
(12:46):
as the reason for the stroke.
So once that is established and thepatient has begun recovering from their
stroke symptoms and is improving atthat point we discuss with the patient,
there are different optionsfor carotid revascularization.
So the goal of the surgery is to alleviatethe narrowing of the carotid artery
(13:07):
and prevent future embolicevents from causing strokes,
meaning preventing that plaque frombreaking off and going off into the brain.
There are three major types ofinterventions that we can offer or carotid
disease. The first one iscarotid endarterectomy.
So carotid endarterectomy is the,I would say the gold standard of
interventions. It is, as layman might say,the traditional open surgical option.
(13:32):
Which means cutting open the neck.
Correct. So this means making an obliqueincision in the neck, not very large,
and identifying the carotid artery,making sure to avoid the nerves
that kind of live in that region.
There are nerves therethat help control speech,
swallowing your tongue movement.
And once the artery is identified,then you, for lack of a better word,
(13:54):
you open up the artery and youkind of scoop the plaque out,
making sure to remove theentirety of the plaque,
making sure that there's going to be agood passage of blood through there with
no further loose segments that couldkind of travel up into the brain.
And then the artery is closedusing what we call a patch.
So it's a piece of prosthetic material.
The reason we use that is that sowe don't artificially widen, sorry,
(14:17):
narrow the artery when we close it. Soyou want it to be nice and open and wide.
So how is this done and stillmaintaining blood flow to the brain?
Because we understand that if the bloodflow stops, the brain stops functioning.
Correct? Correct. So as part ofperforming carotid endarterectomy,
we are monitoring cerebralperfusion throughout the procedure.
(14:38):
So there are a couple ofdifferent ways to do that.
You can monitor cerebral oximetry,you can monitor brain
function with EEGs and otherbrain monitors.
You can do a direct measurement of thepressure in the carotid artery after you
clamp it. And the brain is awonderfully designed organ.
(14:59):
And as we talked before,you have your other side,
presumably we'reoperating on the one side,
but the other side is open andflowing through there, and.
That other side can stillappropriately feed the rest of the.
Correct. So there are importantcollateral circulation pathways.
So collateral circulation isbasically kind of back channels.
(15:21):
Through which, okay, shared.
Blood supplies between thetwo sides of your brain,
and it can also recruit blood from theposterior circulation of your brain as
well. It's a well establishedpathway called the circle of Willis.
Different patients have differentpatency of these pathways.
Some people have a completecircle of Willis, others don't.
So when we are doing acarotid endarterectomy,
(15:42):
we're monitoring someone's brain perfusionthrough one of the many different
ways that we can.
And if we notice during the procedurethat the profusion to the brain is being
affected and that the other side or theposterior circulation cannot compensate
for the interruption in blood flow,then we can place a temporary shunt.
So it's a temporary plastic tube goingfrom the proximal carotid artery to the
(16:06):
distal carotid artery that we canwork around to remove the plaque.
Now, as someone who hasnever seen a carotid artery,
I'm trying to grasp what that would looklike. I'm picturing a drinking straw,
and the narrowing of it might be likethen a coffee stir is that am my way out
of the realm of realityin that description.
So it's kind of similar to if youthink of plumbing in your house,
(16:29):
if you think of a pipe in your house,and sometimes you can have the
buildup of debris inside the pipe,and sometimes you can snake a
drain into the pipe and get thatdebris out, and other times you have
to replace that segment of the pipe.
So that's kind of how I would describe it.
It's like taking a pipe with some debrisin it that's stuck in there and you're
(16:50):
opening up that pipe,scooping up that debris,
making sure there's nothing leftthere to clog up your system.
How do you make sure that the gunk thatyou're scraping out of that pipe doesn't
get caught up in a blood flow andthen move on up into the brain?
So when we interrupt the bloodflow to the brain on that side,
that stops the risk of thatdebris going up into the brain.
(17:11):
No chance of that happening?
Yes. Once we clamp theartery, yes. But before that,
correct, once the arties clamp, therisk is minimized. But before that,
obviously when you'remanipulating the artery,
there's always a chance that a piece ofthat plaque will go up into the brain.
That's one of the majorrisks of the surgery.
It's kind of amazing to me to thinkthat you can actually see the plaque.
(17:31):
Yes.
And actually scoop it outwith plaque. I don't know.
What kind of tool wouldyou scoop it out with?
So you scoop it out using and spatula or afreer elevator. So you develop
a plane behind the plaque,ensure to get it all out. You try
to get it all out in one piece.
How big is that? How big thatcarotid artery is it, like I said,
(17:51):
a drinking straw size.
Bigger? Yeah, so it's probablymost carotid arteries.
We're not talking about amicroscopic vessel though.
No, no. Most carotid arteriesare about a centimeter wide.
And then once it dividesinto your internal carotid,
I would say most internal carotid arteriesare around five to six millimeters.
So it's smaller even thanI thought. Then I think.
(18:12):
Yeah, probably a little bitsmaller than a drink and straw.
So when it gets narrow, it's verynarrow. It's actually really small.
So the trickling, it couldstill trickle through that.
The stenosis we arereferring to the narrowing,
it's actually called stenosis.
When there is a stenosis where thevessel is STS stenotic a slower blood
flow,can that still indicate a stroke or
(18:33):
cause a stroke or as long as it's gettingthrough?
It can. It can,but the majority of the time it's small
pieces of that plaque breaking off andgoing up into the brain.
Okay. Yeah. So it's very importantto get that material out.
So either get it out or place a stentacross it that will prevent or minimize
(18:54):
the risk of those pieces breakingoff and going into the brain.
So the stent will keepthat from falling off.
I thought the stent would justopen it up and widen the artery.
So the stent will widenthe artery to an extent,
but it'll also trap that plaqueand minimize the chance of
any of that breaking off andgoing down into the brain.
So that's the other option.
Carotid artery stenting CAS?
(19:17):
Correct. So there areactually three options.
So the one we discussed earlierwas carotid endarterectomy,
which is kind of moretraditional open surgery.
And then carotid artery stenting wasfor a long time. The other option,
and that involves placing astent in the carotid artery,
most commonly coming fromthe groin or the wrist,
similar as one would come for a lowerextremity angiogram or a heart angiogram
(19:39):
or something like that.
It involves getting across thearea of the narrowing with a wire,
placing a protective filter tocatch any possible debris that
you might agitate from the plaque.
Where is the filter?
The filter's deployed above the lesiononce you cross it with the wire.
And that helps to catch anythingthat might fall off the plaque while
(20:03):
you're putting your stent up.
So it doesn't stay in there.
The filter? No, it doesn't stay in.
It's something that you put up andthen you recapture and bring outside.
And more recently, kind of a hybridtechnique has been innovated.
Proposed is very common now it'scalled the trans carotid arterial
revascularization or TAR for short.
And thistechnique kind of merges components
of open and endovascular surgery.
(20:27):
So it involves making a smallincision at the base of the neck,
so not exactly where you would makea carotid endarterectomy incision.
Through that incision, you find whatwe call the common carotid artery,
which is an area lower down thanwhere the narrowing is that's causing
the problem. And once identify that,then you access that with a needle and
(20:48):
you place your wires and your catheters,and through that, you place a stent.
The benefit of that is that you'reable to control the blood flow up to
the brain in a similar way that youwould in a carotid endarterectomy,
which can drastically minimize the riskof stroke because of the procedure.
(21:08):
So whenever we think of anyprocedure for carotid surgery,
whether it's endarterectomy,carotid artery stenting, or TAR,
one of the things that we talk to patientsabout the most is the risk of stroke
because the procedure itselfcan cause a risk of stroke.
And then the second thing we talk aboutspecifically for carotid endarterectomy
and to some extent trans carotidarterial revascularizations or TAR,
(21:31):
we talk about the risks of nerveinjury. As we talked about,
there are some nerves in the area ofcarotid artery that we have to be very
vigilant for when we are performingopen surgery in this area.
What could happen ifthere is nerve damage?
So if there is nerve damage, sometimesthere's issues with tongue movement.
So one of the nerves is verygro in controlling your tongue,
(21:53):
which can affect speech,which can affect swallowing.
Some of the other nerves directlyinvolve control of your vocal cords,
which can affect the injury.
Some of the nerves can affectthe quality of your voice,
so you can have some hoarseness andsometimes it can cause inability to
properly move your vocal cords, whichcan again affect speech and swallowing.
(22:15):
Sounds like the risks are rather high.
They are, but the rewardis also high as well.
So for a lot of these patients,their risk of recurrent stroke after
the initial episode remains pretty high,even with maximum medical therapy.
So that's why for patients who havehad the documented stroke or TIA,
(22:35):
the risk of intervention is farless than the benefit they gain
from the surgery or stent.
Is that just a fine print or does.
It No. So how often does a stroke happen?
I mean these repercussions such as nervedamage or a stroke is because of the
procedure.
Correct? Yeah. So I would sayit's probably less than 0.5%.
So.
Stroke is maybe 0.5 to 1% andnerve injury is less than 0.5%.
(22:59):
So it's rare, but we talk aboutit because when it does happen,
it can affect thepatient's quality of life.
If it happens on one side ofthe carotid, as we talked about,
it splits off there's two sides,is it likely to also this
stenosis or this narrowing orblockage going to happen the other side?
It definitely could.
(23:19):
When we are following patients in theoffice who have asymptomatic carotid
artery stenosis where we oftenfollow both sides with an ultrasound,
we are obviously very vigilant to makesure that the other side doesn't develop
stenosis.
Or if it does that we stay on top of itand we make sure that if it gets severe,
we're having the appropriatediscussions with the patients.
(23:39):
What are you able tosee with the ultrasound?
Can you actually see anarrowing that's dangerous?
Yeah, so ultrasounds areactually, in my opinion,
one of the best initial tests to getfor carotid artery stenosis for when
patients come into my office.
So if a patient, for example,is referred into my office because of
either an incidental finding that someonenoted on a CT scan or on a physical
(24:00):
exam someone heard abnormalflow in their carotid artery, getting an
ultrasound is vital because number one,it can show you what the artery
looks like on ultrasound,so it can show you areas of plaque and
hardening and narrowing. And secondly,it shows you the P of blood flow
through the area of narrowing,which can give you a very good estimate
(24:21):
as to how severe the narrowing is.
And there's very good data that correlatesthe speed of blood flow through the
narrowing to how severe the narrowingis to when you should consider
interventions in these patients.
These procedures, once they happen.
Now I'm talking about the CAS,the TAR and the CEA,
(24:43):
presumably they're under generalanesthesia and then they spend a night,
two nights. What's thefollow up and recovery?
So it depends. Different people,different proceduralists,
different interventionalistsperform these differently.
I would say for the majority of patients.
For me, carotid endarterectomies,I do under general anesthesia, TAI do
the majority under general anesthesia,however, it's been described that
(25:05):
you do those under sedation as well.
Some people do that as a way ofmonitoring the flow to the brain.
Here at MedStar, the way I do them,as I do endarterectomies in
TA under general anesthesia,when we place a carotid
stent from the groin,typically those patients are done under
a little bit of numbing medication and alittle bit of sedation,
but they're more awake because that'show we monitor blood flow to the brain.
(25:29):
We continually talk to the patient,ask them to say words or squeeze
squeezey toy that makes noise,make sure they can follow commands,
make sure the procedure's going well.
All of these patients spendone night in the hospital.
The goal of that is to make sure thatwe're monitoring them closely afterwards,
making sure there are no issues,no recurrence, stroke symptoms.
(25:51):
We're monitoring their blood pressure.
You want to have very good control ofsomeone's blood pressure after the surgery
to prevent certain complications.
And the majority of the patients,I would say 99% go home the next
morning or the next afternoon.
If they come in with strokesymptoms because of the blockage.
Once that repair is made, is itrevocable, is it recoverable?
(26:13):
So a lot of times when patientscome in with severe stroke symptoms,
we begin the medical treatment andthen we give the patient some time to
start to recover. So more often than not,we are already seeing recovery from
their stroke At the time that we do thisprocedure,
the patients typically tend to continueto improve from their stroke symptoms.
So like the speech you mentioned,the ability to eat or what about
the blindness? The vision issues.
(26:38):
So sometimes that's permanent.
It depends on when theypresent and how they respond to
the medications initially.
But we tend to give themsome time after their stroke
to recover for the brain to showsigns of recovery before we pursue
revascularization of their carotid.
What about rehabilitation?
(26:59):
Of course. Of course. As part of thecomprehensive stroke care that we provide,
you're evaluated by the rehabprofessionals before discharge.
And every patient will have differentneeds depending on their level
of support at home, how wellthey're progressing from the stroke,
how quickly their symptoms are improving.
We talked a little bitabout who is at risk,
(27:20):
but what are some of the other causesfor something like this to happen?
Is it usually, do you findin the family history?
I would say the major risk factors fordeveloping carotid artery disease is the
presence of otherdiseases. So like I said,
it is a disease of advanced age, and wedo see that with every decade in life,
(27:41):
the risk of developing carotidartery disease increases.
Smoking is definitely one ofthe modifiable risk factors,
the presence of any clinicallyevident peripheral arterial disease.
So if someone has evidence of vasculardisease in their legs, their arms,
their heart,that puts them at a higher risk of
also having disease in their carotids.
(28:02):
At the same time, patients withhigh blood pressure, diabetes,
high cholesterol,or all conditions that are associated
with carotid artery stenosis,in addition to the
presence of, like I said,heart disease and
abdominal aortic aneurysms.
If someone who's had a cardiaccatheterization and had stents put in,
should they get an ultrasoundautomatically in their there?
(28:25):
So that's a very good question.
When we think about screeningin the general population,
we think about maximizingthe benefit to the patients.
So we want to screen to preventbad outcomes from happening.
When we look at the data that's availableto screen the general population for
carotid disease,it's not recommended at this moment to
screen the general population for carotiddisease. However,
(28:49):
certain populations are recommendedto be screened for carotid disease,
and those are the patientsthat are at higher risks,
anyone with clinically significantperipheral vascular disease.
So someone who's been diagnosed withclaudication or rest pain in their
extremities,patients who are over 65 with evidence
of heart disease like you mentioned.
So if someone had a heart catheterization,had stents and they're over 65,
(29:12):
they should get a screening carotidultrasound over 65 with heart disease,
smoking and high cholesterol so thatthose three conditions and the age of
65, those patients have abenefit to being screened.
And then patients who have heart diseasethat requires open heart surgery,
those patients should be screened forcarotid disease and are typically screened
as part of the workupfor open heart surgery.
(29:34):
Yeah, I think I would just want tobe screened if I had a cardiac stent.
Because.
Your body wants to producearterio sclerosis or a plaque,
I'd be very nervous about what washappening in my carotid artery.
And I think we see that the majority ofthose people do end up being screened
because when you think aboutthe criteria that I mentioned,
65 with heart disease, smoking and highcholesterol, and more often than not,
(29:58):
patients who have heart disease tendto be smokers or history of smokers and
have high cholesterol.
So a lot of the patients who end uphaving clinically demonstratable heart
disease do end up gettingscreened for their carotids.
And on the flip side,should someone who's had a coronary
artery problem or a blockage stenosisbe screened for cardiac stenosis.
(30:20):
If you have carotid artery disease,more often than not you fulfill the
criteria to get screened for vasculardisease in your other beds.
What role do statins and blood pressuremedications play in managing carotid
artery disease?
Yeah, so carotid artery disease, likea lot of times as a disease process,
we see in outpatientevaluations of patients.
(30:40):
So we discussed the patient that comesin with an acute stroke to the hospital
and how that kind of unfolds,but more often than not,
we see patients with carotidartery stenosis in our offices and
whether they have symptoms orasymptomatic risk factor modification or
medical management is paramountin patients with this condition.
(31:02):
And statins play a vital role inmodulating plaque all over the
body. And the way they work obviously,is by decreasing your
LDL or your cholesterol,your bad cholesterol,
and increasing your HDL,which is your good cholesterol and
controlling your triglycerides,which is kind of the fat
content in your blood.
But other schools of thought aswell indicate that not only do
(31:25):
statins kind of give youa better lipid profile,
which is the numbers that patients whoare on statins check to make sure their
cholesterol is headedin the right direction.
Some studies suggest that statinsthemselves provide stabilization of the
plaques so they can also just makethese plaques or these narrowings less
problematic or less likely tocause an embolization event,
(31:47):
which could cause a mini stroke or astroke. And then blood pressure control
obviously is vital for overall health,minimizing disease progression
and for perioperative managementfor the patients who
qualify to get a procedure.
Now, I did read while researchingthis before we met today,
that there is some debate over thebest approach to treating asymptomatic
(32:11):
patients. So patients maybe who foundthat they had a stenosis or a blockage
incidentally, should they betreated? What's your opinion on that?
Yeah,I think that's a very common
topic of debates in the vascularsurgery world.
The treatment of asymptomaticpatients with carotid artery stenosis,
(32:31):
like we talked about,one of the major risk factors
of the procedure is strokealso trying to do is you're
trying to prevent a stroke.
So the studies that we have available tous that kind of guide the treatment of
carotid disease, whether it's symptomaticor asymptomatic or on the older side,
now they're very good trials, very gooddata, but it's a little bit outdated.
(32:53):
And one of the biggest,I think landmark trials in the carotid
surgery world is ongoing today.
It's looking at stenting versusendarterectomy and symptomatic versus
asymptomatic. So hopefully we'll have amore data-driven answer soon. However,
to your point,a lot of different providers treat
asymptomatic disease differently.
The way I treat asymptomatic diseasepersonally is when I identify a patient
(33:17):
with an asymptomatic stenosisabove 50%, but less than 70,
I tend to discuss medicalmanagement with them, counsel.
And when you say 50%, youmean 50% of it is close, so.
Correct.
So the way we classifynarrowings typically when
office is we classify themas 50 to 69% and greater than
(33:39):
70% less than 100.
And then there are certain features onultrasound that can indicate a higher
than 80% stenosis as well.
And those you would treat.
Yeah.
So when I look at a patient with anasymptomatic carotid artery stenosis of
about 50 to 69%, I would focuswith them on smoking cessation.
If they're smoking,I would recommend nicotine
replacement therapy.
(34:02):
Other therapies recommend them to see asmoking cessation counselor provide them
with all the support that theyneed to go down that path.
The journey of quitting smoking,I would discuss with their primary care
physician to ensure that they're on ahigh dose statin, they're on an aspirin,
that their blood pressureis well controlled, their
(34:23):
and start the medicalrisk factor optimization.
And I would follow them with ultrasoundsin my office at predetermined interval.
So I would see them again in six months,and then I would start
seeing them every year.
That way we can keep an eye on thenarrowing and see if it gets worse. For
patients who have severenarrowings over 80%,
(34:43):
I would have another in-depthconversation with them about the risk of
intervention.
I would discuss with them that you're acandidate for endarterectomy or you're a
candidate for a stent depending ontheir physical fitness, their anatomy,
all that stuff.
And then what I would really wantto make sure is that they're really
(35:04):
in good health because when you lookat the data that exam and treating
asymptomatic carotid stenosis,you really want patients to have a life
expectancy of at least three to fiveyears for them to reap the benefit
of this preventative procedure.
What's the oldest patient that you'vetreated and what's the youngest?
I would say the youngest with theyoungest with a carotid artery problem was
(35:26):
probably in their early fifties.
And it was shocking because I wasactually managing their lower
extremity arterial disease,and I had done a couple
of procedures on them,and they were on the way
to recovering from that,and they called the
office and they were atwork, and they reported that they
(35:47):
needed to speak to the doctor.
I was in clinic, finished up my patient.
I called them back an hour later,and in my mind I was like, there's
going to be a problem with, God forbid,the bypass or the blood
flow to the leg, et cetera.
And I started asking them about theirleg and how the operation was and if
(36:08):
everything's okay, and they'relike, oh yeah, everything's fine.
Everything's fine. I'm just,every couple of minutes,
I just can't see out of my left eyeanymore. Huh. That's interesting.
Have you ever had this lookedat, et cetera. He's like, no,
it's just been happening for about aday and a half straight every couple of
hours. I can't see out of my lefteye though. I gave him a call.
I was on the phone with him. I toldhim, please come to the office today.
(36:32):
I think there might be something goingon in your carotid artery, et cetera.
And they were able to come into theoffice and we did an ultrasound,
which showed very, very severestenosis of their carotid artery.
And we could see on the ultrasoundthat plaque there looked like it may be
unstable. It did not looklike a normal plaque.
(36:52):
So I recommended to him that Iwant to admit you to the hospital,
put you on some blood thinners, get someimaging and fix this. And thankfully,
he was agreeable.
He was able to figure things out atwork and family and childcare and
everything, and we got him acrossthe street to the hospital.
We got him admitted.
I think the next day we ended updoing a carotid endarterectomy.
We got a CT scan, an MRIdidn't show any acute stroke,
(37:15):
and his vision was back to normal.
Good.
So he was classified as havinga TIA and that we talked about
earlier.
Right.
And he underwent a carotidendarterectomy and he did. Well, thank.
Goodness he communicated that with you.
Yeah, I was glad.
Could that damage have been permanent?
It could have for sure. It couldhave. And for him specifically,
(37:39):
he was already on medical therapy forhis lower extremity arterial disease,
so that was even more jarring to me, andthat's why I felt the need to tell him,
you're already on pretty much max doseanti-platelet medications and a blood
thinner, and you're havingthis problem that's ongoing,
so I think this is something weneed to address really quickly.
And he was young, hadyoung kids, and so it was.
(38:01):
Successful.
Thankfully. Yes. Yeah.
Do you see carotid diseasetreatment changing much in
Where are we headed?
Carotid disease and vascular surgery ingeneral is an ever-changing field where
I think that the introduction of transcarotid arti revascularizations or
TAR has been fantasticbecause it's expanded.
(38:23):
The patients that now haveaccess to carotid therapy.
A lot of patients were lost in theshuffle where they didn't have good
anatomy for a stent or were too highrisk to get a stent from the groin
because of their anatomyand the risk of stroke,
but they were too high risk for acarotid endarterectomy because of neck
(38:43):
anatomy or prior surgeriesor radiation, what have you.
And then this hybrid procedure,it's not very new now.
It's been out for a few years,but as it's becoming more and more
adopted and more and more an option forpatients, and more and more
surgeons are facile with it,I think it's been a great
advancement of the field of carotidtreatment,
(39:08):
and I think minimally invasive techniqueswill continue to improve in vascular
surgery as well as in carotid surgery,and I'm excited to see
what's on the horizon.
Do you love what you do?
I do very much, yeah.
Did you always want tobe a vascular surgeon?
I knew I wanted to be a surgeon ata very young age. How old were you?
I was probably 11 or 12 years oldwhen I knew I wanted to be a surgeon,
(39:30):
and I think my fascination withsurgery was such that every
rotation I would go on as a medicalstudent, I would be enthralled by it.
I'd go on orthopedic rotation. Thisis amazing. I do ENT. I'm like,
this is incredible plastic surgery. Wow.
I'm amazed at everything.
And ultimately,I started out in general surgery
because I knew I wanted to be a surgeon,but I just wanted to see more.
(39:55):
Then early in my general surgery training,I did a vascular surgery rotation,
and I was just amazed at what we'reable to do through a remote access
point in the body sincethe wrist or the groin,
and you can treat the toeor the brain, and it's
in the same breadth of one day youcan do an open surgery on someone's
(40:17):
abdomen and then treat their leg througha minimally invasive poke in the groin,
and then the next phone callis about someone's carotid,
and you're dealing with all aspects ofthe body, all different vascular beds,
and it's very rewarding.
What I think I like the most aboutvascular surgery is you still have to be a
doctor in a way. You followa lot of our patients,
(40:37):
we follow them longitudinally.
We develop a very close relationshipwith them, not just as surgeons,
but also as medical doctors working veryclosely with the primary care doctors,
the cardiologists, theendocrinologists, the podiatrists.
You're very much involved in thepatient's long-term longitudinal care,
(40:58):
which is very nice for me as a doctor.
Well, thank you,Dr. Abdul Malak for sharing your expertise
with us here on MedStar Health DocDog. Of course. To make an
appointment with Dr. Abdul Malak,contact 4 4 3 7 7 7 1 900.
That's 4 4 3 7 7 7 1 900.
(41:19):
If you would like to provide feedbackon this podcast or get more information
when carotid artery disease ortreatment options, send me an email,
Debra schindler@medstar.net.
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