[music] i've performed over 1600 carotid andarteritic procedures at johns hopkins over the years, but without question the mostrewarding and gratifying part of my practice in terms of carotid disease,is reassuring patients that they don't need an operation and they're not athigh risk of stroke. stroke, in my opinion, is the most devastating complication ofcardiovascular disease. it devastates lives. one year after stroke, two-thirds of
survivors are left with significantfunctional deficits. that's our third leading cause of death,our second leading cause of dementia and the number one cause of adultdisability in america today. and patients are terribly scared when theyhear the word stroke. i see lots and lots of patients, almost ona weekly basis, who have had a duplex scan, often in acommunity screening, a study. and they have a piece of paper that says they have carotid disease and they're atrisk of stroke. and we see them.
we evaluate them comprehensively, we get a duplex scan in our accredited vascularlaboratory and find that they only have modest disease at most and they're best treatedmedically. i've got patients like that i've beenfollowing for ten or 20 years. i enjoy performing carotid surgery, butit's terribly gratifying to be able to put someone's mind at ease. tell them they don't need an operation,and they're not at risk of stroke. the term vascular surgeon is really amisnomer because
vascular surgeons do much, much more thanconventional surgery. we diagnose the condition, we perform theduplex scans in our vascular laboratories. and we perform both carotid and arterectomy, and carotid angioplasty andstent procedures. i think it's, it's sort of important toemphasize that only when a patient sees a physicianor group of physicians who have all the tools intheir toolbox, we have all of the modalities oftreatment available. only then will that patient be guaranteedthat they're gonna get the treatment that
they're most in need of rather than a particular treatment that a particularspecialist offers. the carotid arteries are the two majorblood vessels in the neck, one on each side that deliver blood andoxygen to the brain. carotid artery disease refers to theprogressive blockage of these vessels due to the build up of plaque made up of cholesterol, calcium,fibrous tissue and blood clots that deprives the brain ofadequate oxygen. [music].
there are over 700,000 strokes that occureach year in the united states. and carotid artery disease is one of the most important and completely preventablecauses of stroke. stroke occurs when these blockages in thecarotid artery limit blood flow so that cell deathoccurs. or when bits of the plaque break off andlodge in the tiny vessels in the brain, again limiting oxygen supply,leading to cell death and the development of a clinicalstroke. the prevalence of carotid artery diseaseincreases with advancing age.
although it can occur in youngerindividuals, most patients are over the age of 65. other factors that contribute to thedevelopment of carotid artery disease include high blood pressure, hypertension, elevatedcholesterol levels. diabeties and certainly cigarette smoking. the most appropriate treatment for apatient with carotid artery disease depends on twofactors. first, the severity of the blockage itselfand the patient's symptomatic status.
the severity of the blockage is bestdetermined by performance of a carotid duplexultrasound examination. this is a noninvasive, relatively quick,and relatively inexpensive test that not only tells us how severe theartery is blocked. but also allows us noninvasively toexamine the plaque, and the character of that plaque, which hasfuture prognostic significance. the other issue is the patient'ssymptomatic status. most patients with carotid disease arecompletely asymptomatic when they present. and when we know about them, it'stypically because they've had a [unknown]
or a sound in the neck that was picked upby a stethoscope. for those patients, unless the blockage is really severe, the optimal treatment ismedical management. this includes the use of aspirin which is a powerful anti platelet or anti clottingdrug. use of stat medications which not only lowers cholesterol levels but actuallystabilize the plaque itself and has been shown in numerous studies to reduce stroke risklong term.
and good blood pressure control and againcertainly stopping smoking. on the other hand, once a patient hasbecome symptomatic, that is either had a stroke or a so called mini stroke or tia transient ischemic attack, thenintervention is required. the standard conventional treatment forsymptomatic carotid disease and also asymptomatic disease thatis very, very severe, that is typicallygreater than 80% blocked, is a carotidendarterectomy. this operation is really the gold standardtreatment for carotid disease.
it's been around, it's been performed formore than 50 years. and it's been highly studied and very wellperfected. in this operation the surgeon makes anincision over the artery, opens the vessel and directlyremoves the plaque. and then repairs the artery. it can be performed either under generalanaesthesia or with local anaesthesia by numbing the skin, depending upon thesurgeon's and the patient's preference. it takes about an hour to do theprocedure, and recovery is very quick. most patients are discharged the day aftersurgery.
an alternative to carotid endarterectomytoday is carotid angioplasty and stenting. this is generally reserved for patientsconsidered to be at too high risk for open surgery and it's, it's an approach that is still under clinicalinvestigation. in this procedure, the skin in the groinis numbed up with a local anaesthesia, a needle is introduced, a catheter is introduced, and threaded up into thecarotid artery. dye is injected, and a picture on ourturogram of the carotid artery is obtained, andthen a
balloon is inserted and dilated up, toopen the blockage, and then a stent is usual,usually placed. they hold the blockage open and againafter carotid angioplasty and stent and recoveryis very quick. most patients go home the day aftersurgery. recovery from carotid endarterectomy isvery rapid. really, patients resume their normalactivities just a day or two after being discharged from ahospital. the one exception is because there's a, anincision in the neck and it may be
a bit sore, we encourage patients not to drive themselves for about a week or tendays. because changing lanes might be a littlebit of a challenge in similarly after carotid angioplasty your stem procedurebecause the groin might be a little bit sure. again we ask patients not to drive forabout a week after the procedure but generally patientsimmediately return to the normal quality and status of life. although we perform these procedures toprevent stroke, stroke
is one of the potential complications ofthese interventions. in a recently completed nih trial, thecrest trial, the incidence of stroke was about2%. that is one in 50 patients who had acarotid endarterectomy versus 4%, one in 25 patients who underwent acarotid angioplasty and stent procedure. in general, i like to see my patients afew weeks after surgery just to make sure the incision's healing after a carotidendarterectomy or the groin looks okay after a carotidangioplasty extent procedure. and then, we have the patients return oncea year,
and at that time obtained a carotid duplexultrasound examination. not only to look at the artery that we treated, but also to look at the othercarotid artery on the other side of the neck to make certain that it's not developing newdisease down the line. it is very important that the carotid duplex scan be performed in an accreditedlaboratory. ultrasound machines are available in manyphysician's offices, and healthcare clinics, and walk in clinics, and theseare very critical tests.
the decision as to how we treat a patientis dependent upon the information that comesout of these tests. and only when a patient is evaluated in atruly accredited vascular laboratory that has tomeet very rigorous criteria can they be certain that the information thatthey're being given is truly accurate in terms of determiningtheir most appropriate treatment. and as chief of the division of vascularsurgery and endovascular therapy, i'm most proud ofthe team that we've recruited. our vascular team at johns hopkins, all ofuse share a common vision.
we believe our mission is not to take careof disease. our mission is to take care of people. we're all committed to one goal, that isto do the most appropriate thing to optimize thevascular health of our patients. johns hopkins has a well deservedreputation as an outstanding center for research andteaching. and we're an international center ofexcellence in clinical care. diagnosing and treating the entire gamutdisease from the various attack to the every dayroutine processes.
i think sometimes what gets lost in thiswell-deserved reputation is the human touch inherent in the carethat we deliver. johns hopkins physicians truly care aboutpatients as people. and that's something that we're most proudof.
