What's Carotid Artery Disease?

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.

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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.

Transcript

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Comprehensive, relevant and insightful conversations about health and medicine happen here on MedStar Health Doc talk. These are real conversations with physician experts from around the largest healthcare system in the Maryland DC region. How many times have we seen it in the movies? Someone checking a victim's pulse by holding two fingers against their neck. It's the carotid pulse they're looking for, but why? Well, carotid arteries are major vessels that supply blood to the head because they're so large. They have a detectable pulse longer than other sites like the wrist when blood flow is weak and there are two of them creating a pathway on each side of the neck for blood to get to the brain, face and neck. But what happens if the blood flowing through the carotid artery is blocked? In truth, there aren't always symptoms and 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. Welcome Dr. Abdul Malak. Thank you, Debra. It's a pleasure to be here. Talk about this very important topic. Carotid artery disease was once described to 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 carotid artery disease? What is it exactly? The carotid arteries are, I would say, your two major arteries that provide blood flow to your brain and allow us to continue to function in a normal way. And like any other blood vessel in the body, they're susceptible to becoming diseased, which can cause narrowing of the artery and disruption of this blood flow to the brain, either by slowly narrowing over time or narrowing occurs more suddenly and small pieces of that narrowing can break off and go deeper into the brain causing potentially a stroke or other symptoms such as mini strokes, et cetera. Does a piece like that have to come off for a stroke to happen? There are two major types of stroke. One type is hypoperfusion or a decreased flow to the brain from the narrowing, but the more common type of stroke is an embolic kind of stroke, meaning that a small piece, sometimes even microscopic, can break off and go deeper into the brain circulation affecting certain regions of the brain, which can manifest itself as a stroke, such as weakness of the arms of the legs, numbness and paralysis of the extremities, what we commonly refer to as a facial droop altered speech, it can affect the vision as the carotid artery supplies blood flow to your eye and your retina. So that's one of the more common symptoms of carotid artery stenosis or symptomatic carotid artery stenosis. Patients will typically describe kind of black curtain coming down over their eyes, kind of like you're watching the opera and it's the end of the show that's typically referred to as amaurosis fuac. So there's a very common that sometimes patients will describe, they'll come to our office and say, I feel okay, but every once in a while I just get this black curtain that comes down over my eye on the one side and it goes away after a couple of seconds, and that's a piece of the plaque breaking off lodging in that area of the eye for a little bit and then your body will kind of break it down. But that's one of the first signs that there 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 once it 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'll filter off into a smaller blood vessel and you'll get your vision back. But the main issue would then be to treat the carotid artery in the neck, which is the source of these small emboli that go up into your brain causing these stroke-like symptoms. What is that exactly? The MI that's floating around So when you get hardening or disease in your carotid arteries, like other arteries in your body, your body will deposit cholesterol and other particles within the layers of your artery causing a plaque and pieces of that plaque break off and go into your brain. Okay, so it's part of that hardening of the arteries? Correct. Okay. Who's at risk for this? So the majority of patients with vascular disease and heart disease are at risk for this. When we look at the population in general, I would say the prevalence of any level of carotid disease is probably around 21% of the general population. When we look at the prevalence of clinically significant carotid artery stenosis, we're probably looking at something like around 4% in women in men and two and a half percent in women. And we see that as the population ages, the prevalence in the age population is much higher than in the younger population. So it really is a disease of progressive age. Does it differ when we're talking about the transient ischemic attack TIA or mini stroke or bigger stroke, like what you had described before? Really these are spectrums of the same disease process. So transient ischemic attacks are colloquially referred to as mini strokes. So these symptoms are the same. The difference is that the transient ischemic attacks are typically caused by smaller emboli and they don't leave a visible imprint on the brain, meaning that if you were to have a weakness of your arm, typically it would last less than an 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 your brain that we can measure with imaging such as CT or MRI. But really for all intents and purposes, there are two sides of the same coin. Well, that's interesting. When you talk 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 a mini stroke, more often than not, almost always the MRI or CT 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 this part of the brain was affected by the stroke. When I first started talking about carotid artery disease, I mentioned that sometimes there isn't a symptom and the first sign is a stroke. What are the typical signs when there are signs of carotid artery disease? What might the patient experience and what's the first step? Is it always an emergency? So when we look at carotid artery stenosis and carotid artery disease, I would say the majority of the patients who present with that disease present asymptomatically, meaning it is discovered incidentally, most of the time they go in for their annual physical and as part of their physical exam, the cardiologists or the primary care physicians who are performing this exam will take a listen to their carotid arteries. And what they listen for is what we call a carotid brewery, which indicates that the flow through the artery is there, but maybe not normal. And that leads to a cascade of tests and imaging to detect whether or not there's any carotid artery stenosis. And I would say that the asymptomatic patients are the majority of the patients and the minority of the patients are the ones that present with the typical signs and symptoms of a stroke that 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 area on the side of the artery that is diseased. So someone doesn't have to be doing something incredibly physical or stressful for this to happen, and they just suddenly recognize that their face is drooping or their words aren'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 as weakness of the extremities, then the patient's often aware and they will kind tell you that, oh, I suddenly was holding a cup of water and I lost my strength and sensation and that dropped, or I was using a pen and I lost control of that. I think the first step should be to call 9 1 1 and seek emergency medical care and present to the ER as fast as possible. Because while there are different kinds of strokes, some come from central circulation, heart issues, some are due to the carotid, the key point is that time is brain and the quicker you're at a center that's equipped to deal with a stroke, the better the outcomes are. And nine one one you call 9 1 1 and they're going to know where to go. They're going to know the comprehensive stroke centers. Right. Exactly. Should you take an aspirin. If you have it? Does. That help? I would say I wouldn't take it immediately because some types of stroke are due to bleeding. So you could also have a hemorrhagic 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 the head. So I would say call 9 1 1, try to get to a comprehensive stroke center as soon as possible. And once the first set of imaging is obtained, that will differentiate between a hemorrhagic or ischemic or lack of blood flow kind of stroke. And in the latter, which is the ischemic or lack of blood flow kind of stroke, that's when medications such as aspirin, Plavix, antiplatelet medications and medications such as thrombolytics or clot busters as we refer to them colloquially are useful. Is there any truth to packing ice behind the neck when a patient who is suspected to have no truth to that? No truth to that at all. I can tell by your face. Okay. I don't know where I heard that from. Yeah, I don't know that I've heard that maybe some of my neurology colleagues might weigh in on that, but I don't know that I've heard of that. Well, that's interesting that you raised that too. Should someone get to a vascular surgeon or a neurosurgeon, what's most important? So I think most important is that you get a facility where it's a true comprehensive stroke center where the specialties all work together in tandem. Here at our program at Franklin Square, we work very closely with, as a vascular surgeon, I work very closely with the neurosurgeons, the neurointerventionalists, the neurologists, the neurointensivists, and we're all really a team that come together and take care of the patient. And each specialty weighs in with their area of expertise and what they can provide. And I think that allows for every patient getting the best possible care because regardless of what the thing that is needed the most at the time, we have the ability to provide the patient with that. Absolutely. So a patient comes in a stroke, is suspected, what's the first thing that happens? You mentioned the imaging. Is that the first thing that would happen and what kind of imaging is done? Correct. So when a patient comes in emergently, typically they would obtain a CT scan of 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's dedicated to making sure that the blood vessels of the head and the neck are patent. And oftentimes they add a CT perfusion, which will allow the radiologist and the neurologist to evaluate whether or not there are any perfusion defects or any parts of the brain that are not getting enough blood flow. Are the patients usually conscious for that? It depends on how bad their presentation is, but the vast majority of them would be. So those scans must happen pretty quickly. Very, very quickly. And then depending on what that shows, if there's evidence of an acute blockage of a large vessel, then the neurointerventionalists are called in to weigh in on whether or not they need to provide any emergent services or whether this is something that can be dealt with medications. And then if carotid stenosis is suspected, then we are called in and we kind of weigh in 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 surgery might be needed and what kind of surgery options are there? It looks like a lot of acronyms when it comes to treatment for carotid artery disease. Yeah, so the scenario we were discussing is the one where someone comes in emergently and carotid stenosis is identified as the reason for the stroke. So once that is established and the patient has begun recovering from their stroke symptoms and is improving at that point we discuss with the patient, there are different options for carotid revascularization. So the goal of the surgery is to alleviate the narrowing of the carotid artery and prevent future embolic events from causing strokes, meaning preventing that plaque from breaking off and going off into the brain. There are three major types of interventions that we can offer or carotid disease. The first one is carotid 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. Which means cutting open the neck. Correct. So this means making an oblique incision 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 there that help control speech, swallowing your tongue movement. And once the artery is identified, then you, for lack of a better word, you open up the artery and you kind of scoop the plaque out, making sure to remove the entirety of the plaque, making sure that there's going to be a good passage of blood through there with no further loose segments that could kind of travel up into the brain. And then the artery is closed using what we call a patch. So it's a piece of prosthetic material. The reason we use that is that so we don't artificially widen, sorry, narrow the artery when we close it. So you want it to be nice and open and wide. So how is this done and still maintaining blood flow to the brain? Because we understand that if the blood flow stops, the brain stops functioning. Correct? Correct. So as part of performing carotid endarterectomy, we are monitoring cerebral perfusion throughout the procedure. So there are a couple of different ways to do that. You can monitor cerebral oximetry, you can monitor brain function with EEGs and other brain monitors. You can do a direct measurement of the pressure in the carotid artery after you clamp it. And the brain is a wonderfully designed organ. And as we talked before, you have your other side, presumably we're operating on the one side, but the other side is open and flowing through there, and. That other side can still appropriately feed the rest of the. Correct. So there are important collateral circulation pathways. So collateral circulation is basically kind of back channels. Through which, okay, shared. Blood supplies between the two sides of your brain, and it can also recruit blood from the posterior circulation of your brain as well. It's a well established pathway called the circle of Willis. Different patients have different patency of these pathways. Some people have a complete circle of Willis, others don't. So when we are doing a carotid endarterectomy, we're monitoring someone's brain perfusion through one of the many different ways that we can. And if we notice during the procedure that the profusion to the brain is being affected and that the other side or the posterior circulation cannot compensate for the interruption in blood flow, then we can place a temporary shunt. So it's a temporary plastic tube going from the proximal carotid artery to the distal carotid artery that we can work around to remove the plaque. Now, as someone who has never seen a carotid artery, I'm trying to grasp what that would look like. I'm picturing a drinking straw, and the narrowing of it might be like then a coffee stir is that am my way out of the realm of reality in that description. So it's kind of similar to if you think of plumbing in your house, 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 that debris 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 debris in it that's stuck in there and you're opening up that pipe, scooping up that debris, making sure there's nothing left there to clog up your system. How do you make sure that the gunk that you're scraping out of that pipe doesn't get caught up in a blood flow and then move on up into the brain? So when we interrupt the blood flow to the brain on that side, that stops the risk of that debris going up into the brain. No chance of that happening? Yes. Once we clamp the artery, yes. But before that, correct, once the arties clamp, the risk is minimized. But before that, obviously when you're manipulating the artery, there's always a chance that a piece of that plaque will go up into the brain. That's one of the major risks of the surgery. It's kind of amazing to me to think that you can actually see the plaque. Yes. And actually scoop it out with plaque. I don't know. What kind of tool would you scoop it out with? So you scoop it out using and spatula or a freer 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 that carotid artery is it, like I said, a drinking straw size. Bigger? Yeah, so it's probably most carotid arteries. We're not talking about a microscopic vessel though. No, no. Most carotid arteries are about a centimeter wide. And then once it divides into your internal carotid, I would say most internal carotid arteries are around five to six millimeters. So it's smaller even than I thought. Then I think. Yeah, probably a little bit smaller than a drink and straw. So when it gets narrow, it's very narrow. It's actually really small. So the trickling, it could still trickle through that. The stenosis we are referring to the narrowing, it's actually called stenosis. When there is a stenosis where the vessel is STS stenotic a slower blood flow, can that still indicate a stroke or cause a stroke or as long as it's getting through? It can. It can, but the majority of the time it's small pieces of that plaque breaking off and going up into the brain. Okay. Yeah. So it's very important to get that material out. So either get it out or place a stent across it that will prevent or minimize the risk of those pieces breaking off and going into the brain. So the stent will keep that from falling off. I thought the stent would just open it up and widen the artery. So the stent will widen the artery to an extent, but it'll also trap that plaque and minimize the chance of any of that breaking off and going down into the brain. So that's the other option. Carotid artery stenting CAS? Correct. So there are actually three options. So the one we discussed earlier was carotid endarterectomy, which is kind of more traditional open surgery. And then carotid artery stenting was for a long time. The other option, and that involves placing a stent in the carotid artery, most commonly coming from the groin or the wrist, similar as one would come for a lower extremity angiogram or a heart angiogram or something like that. It involves getting across the area of the narrowing with a wire, placing a protective filter to catch any possible debris that you might agitate from the plaque. Where is the filter? The filter's deployed above the lesion once you cross it with the wire. And that helps to catch anything that might fall off the plaque while 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 and then you recapture and bring outside. And more recently, kind of a hybrid technique has been innovated. Proposed is very common now it's called the trans carotid arterial revascularization or TAR for short. And this technique kind of merges components of open and endovascular surgery. So it involves making a small incision at the base of the neck, so not exactly where you would make a carotid endarterectomy incision. Through that incision, you find what we call the common carotid artery, which is an area lower down than where the narrowing is that's causing the problem. And once identify that, then you access that with a needle and you place your wires and your catheters, and through that, you place a stent. The benefit of that is that you're able to control the blood flow up to the brain in a similar way that you would in a carotid endarterectomy, which can drastically minimize the risk of stroke because of the procedure. So whenever we think of any procedure for carotid surgery, whether it's endarterectomy, carotid artery stenting, or TAR, one of the things that we talk to patients about the most is the risk of stroke because the procedure itself can cause a risk of stroke. And then the second thing we talk about specifically for carotid endarterectomy and to some extent trans carotid arterial revascularizations or TAR, we talk about the risks of nerve injury. As we talked about, there are some nerves in the area of carotid artery that we have to be very vigilant for when we are performing open surgery in this area. What could happen if there is nerve damage? So if there is nerve damage, sometimes there's issues with tongue movement. So one of the nerves is very gro in controlling your tongue, which can affect speech, which can affect swallowing. Some of the other nerves directly involve control of your vocal cords, which can affect the injury. Some of the nerves can affect the quality of your voice, so you can have some hoarseness and sometimes it can cause inability to properly move your vocal cords, which can again affect speech and swallowing. Sounds like the risks are rather high. They are, but the reward is 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 have had the documented stroke or TIA, the risk of intervention is far less 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 nerve damage or a stroke is because of the procedure. Correct? Yeah. So I would say it's probably less than 0.5%. So. Stroke is maybe 0.5 to 1% and nerve injury is less than 0.5%. So it's rare, but we talk about it because when it does happen, it can affect the patient's quality of life. If it happens on one side of the carotid, as we talked about, it splits off there's two sides, is it likely to also this stenosis or this narrowing or blockage going to happen the other side? It definitely could. When we are following patients in the office who have asymptomatic carotid artery stenosis where we often follow both sides with an ultrasound, we are obviously very vigilant to make sure that the other side doesn't develop stenosis. Or if it does that we stay on top of it and we make sure that if it gets severe, we're having the appropriate discussions with the patients. What are you able to see with the ultrasound? Can you actually see a narrowing that's dangerous? Yeah, so ultrasounds are actually, in my opinion, one of the best initial tests to get for 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 someone noted on a CT scan or on a physical exam someone heard abnormal flow 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 as to how severe the narrowing is. And there's very good data that correlates the speed of blood flow through the narrowing to how severe the narrowing is 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, presumably they're under general anesthesia and then they spend a night, two nights. What's the follow up and recovery? So it depends. Different people, different proceduralists, different interventionalists perform 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 you do those under sedation as well. Some people do that as a way of monitoring 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 a little bit of sedation, but they're more awake because that's how we monitor blood flow to the brain. 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 spend one night in the hospital. The goal of that is to make sure that we're monitoring them closely afterwards, making sure there are no issues, no recurrence, stroke symptoms. We're monitoring their blood pressure. You want to have very good control of someone'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 stroke symptoms because of the blockage. Once that repair is made, is it revocable, is it recoverable? So a lot of times when patients come in with severe stroke symptoms, we begin the medical treatment and then 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 this procedure, the patients typically tend to continue to improve from their stroke symptoms. So like the speech you mentioned, the ability to eat or what about the blindness? The vision issues. So sometimes that's permanent. It depends on when they present and how they respond to the medications initially. But we tend to give them some time after their stroke to recover for the brain to show signs of recovery before we pursue revascularization of their carotid. What about rehabilitation? Of course. Of course. As part of the comprehensive stroke care that we provide, you're evaluated by the rehab professionals before discharge. And every patient will have different needs depending on their level of support at home, how well they're progressing from the stroke, how quickly their symptoms are improving. We talked a little bit about who is at risk, but what are some of the other causes for something like this to happen? Is it usually, do you find in the family history? I would say the major risk factors for developing carotid artery disease is the presence of other diseases. So like I said, it is a disease of advanced age, and we do see that with every decade in life, the risk of developing carotid artery disease increases. Smoking is definitely one of the modifiable risk factors, the presence of any clinically evident peripheral arterial disease. So if someone has evidence of vascular disease in their legs, their arms, their heart, that puts them at a higher risk of also having disease in their carotids. At the same time, patients with high 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 cardiac catheterization and had stents put in, should they get an ultrasound automatically in their there? So that's a very good question. When we think about screening in the general population, we think about maximizing the benefit to the patients. So we want to screen to prevent bad outcomes from happening. When we look at the data that's available to screen the general population for carotid disease, it's not recommended at this moment to screen the general population for carotid disease. However, certain populations are recommended to be screened for carotid disease, and those are the patients that are at higher risks, anyone with clinically significant peripheral vascular disease. So someone who's been diagnosed with claudication 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, they should get a screening carotid ultrasound over 65 with heart disease, smoking and high cholesterol so that those three conditions and the age of 65, those patients have a benefit to being screened. And then patients who have heart disease that requires open heart surgery, those patients should be screened for carotid disease and are typically screened as part of the workup for open heart surgery. Yeah, I think I would just want to be screened if I had a cardiac stent. Because. Your body wants to produce arterio sclerosis or a plaque, I'd be very nervous about what was happening in my carotid artery. And I think we see that the majority of those people do end up being screened because when you think about the criteria that I mentioned, 65 with heart disease, smoking and high cholesterol, and more often than not, patients who have heart disease tend to be smokers or history of smokers and have high cholesterol. So a lot of the patients who end up having clinically demonstratable heart disease do end up getting screened for their carotids. And on the flip side, should someone who's had a coronary artery problem or a blockage stenosis be screened for cardiac stenosis. If you have carotid artery disease, more often than not you fulfill the criteria to get screened for vascular disease in your other beds. What role do statins and blood pressure medications play in managing carotid artery disease? Yeah, so carotid artery disease, like a lot of times as a disease process, we see in outpatient evaluations of patients. So we discussed the patient that comes in with an acute stroke to the hospital and how that kind of unfolds, but more often than not, we see patients with carotid artery stenosis in our offices and whether they have symptoms or asymptomatic risk factor modification or medical management is paramount in patients with this condition. And statins play a vital role in modulating 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 as well indicate that not only do statins kind of give you a better lipid profile, which is the numbers that patients who are on statins check to make sure their cholesterol is headed in the right direction. Some studies suggest that statins themselves provide stabilization of the plaques so they can also just make these plaques or these narrowings less problematic or less likely to cause an embolization event, which could cause a mini stroke or a stroke. And then blood pressure control obviously is vital for overall health, minimizing disease progression and for perioperative management for the patients who qualify to get a procedure. Now, I did read while researching this before we met today, that there is some debate over the best approach to treating asymptomatic patients. So patients maybe who found that they had a stenosis or a blockage incidentally, should they be treated? What's your opinion on that? Yeah, I think that's a very common topic of debates in the vascular surgery world. The treatment of asymptomatic patients with carotid artery stenosis, like we talked about, one of the major risk factors of the procedure is stroke also trying to do is you're trying to prevent a stroke. So the studies that we have available to us that kind of guide the treatment of carotid disease, whether it's symptomatic or asymptomatic or on the older side, now they're very good trials, very good data, but it's a little bit outdated. And one of the biggest, I think landmark trials in the carotid surgery world is ongoing today. It's looking at stenting versus endarterectomy and symptomatic versus asymptomatic. So hopefully we'll have a more data-driven answer soon. However, to your point, a lot of different providers treat asymptomatic disease differently. The way I treat asymptomatic disease personally is when I identify a patient with an asymptomatic stenosis above 50%, but less than 70, I tend to discuss medical management with them, counsel. And when you say 50%, you mean 50% of it is close, so. Correct. So the way we classify narrowings typically when office is we classify them as 50 to 69% and greater than 70% less than 100. And then there are certain features on ultrasound that can indicate a higher than 80% stenosis as well. And those you would treat. Yeah. So when I look at a patient with an asymptomatic carotid artery stenosis of about 50 to 69%, I would focus with them on smoking cessation. If they're smoking, I would recommend nicotine replacement therapy. Other therapies recommend them to see a smoking cessation counselor provide them with all the support that they need to go down that path. The journey of quitting smoking, I would discuss with their primary care physician to ensure that they're on a high dose statin, they're on an aspirin, that their blood pressure is well controlled, their and start the medical risk factor optimization. And I would follow them with ultrasounds in 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 the narrowing and see if it gets worse. For patients who have severe narrowings over 80%, I would have another in-depth conversation with them about the risk of intervention. I would discuss with them that you're a candidate for endarterectomy or you're a candidate for a stent depending on their physical fitness, their anatomy, all that stuff. And then what I would really want to make sure is that they're really in good health because when you look at the data that exam and treating asymptomatic carotid stenosis, you really want patients to have a life expectancy of at least three to five years for them to reap the benefit of this preventative procedure. What's the oldest patient that you've treated and what's the youngest? I would say the youngest with the youngest with a carotid artery problem was probably in their early fifties. And it was shocking because I was actually 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 at work, and they reported that they 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 their leg and how the operation was and if everything's okay, and they're like, oh yeah, everything's fine. Everything's fine. I'm just, every couple of minutes, I just can't see out of my left eye anymore. Huh. That's interesting. Have you ever had this looked at, et cetera. He's like, no, it's just been happening for about a day and a half straight every couple of hours. I can't see out of my left eye though. I gave him a call. I was on the phone with him. I told him, please come to the office today. I think there might be something going on in your carotid artery, et cetera. And they were able to come into the office and we did an ultrasound, which showed very, very severe stenosis of their carotid artery. And we could see on the ultrasound that plaque there looked like it may be unstable. It did not look like a normal plaque. So I recommended to him that I want to admit you to the hospital, put you on some blood thinners, get some imaging and fix this. And thankfully, he was agreeable. He was able to figure things out at work and family and childcare and everything, and we got him across the street to the hospital. We got him admitted. I think the next day we ended up doing a carotid endarterectomy. We got a CT scan, an MRI didn't show any acute stroke, and his vision was back to normal. Good. So he was classified as having a TIA and that we talked about earlier. Right. And he underwent a carotid endarterectomy 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 could have. And for him specifically, he was already on medical therapy for his lower extremity arterial disease, so that was even more jarring to me, and that's why I felt the need to tell him, you're already on pretty much max dose anti-platelet medications and a blood thinner, and you're having this problem that's ongoing, so I think this is something we need to address really quickly. And he was young, had young kids, and so it was. Successful. Thankfully. Yes. Yeah. Do you see carotid disease treatment changing much in Where are we headed? Carotid disease and vascular surgery in general is an ever-changing field where I think that the introduction of trans carotid arti revascularizations or TAR has been fantastic because it's expanded. The patients that now have access to carotid therapy. A lot of patients were lost in the shuffle where they didn't have good anatomy for a stent or were too high risk to get a stent from the groin because of their anatomy and the risk of stroke, but they were too high risk for a carotid endarterectomy because of neck anatomy or prior surgeries or 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 for patients, and more and more surgeons are facile with it, I think it's been a great advancement of the field of carotid treatment, and I think minimally invasive techniques will 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 to be a vascular surgeon? I knew I wanted to be a surgeon at a very young age. How old were you? I was probably 11 or 12 years old when I knew I wanted to be a surgeon, and I think my fascination with surgery was such that every rotation I would go on as a medical student, I would be enthralled by it. I'd go on orthopedic rotation. This is 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. Then early in my general surgery training, I did a vascular surgery rotation, and I was just amazed at what we're able to do through a remote access point in the body since the wrist or the groin, and you can treat the toe or the brain, and it's in the same breadth of one day you can do an open surgery on someone's abdomen and then treat their leg through a minimally invasive poke in the groin, and then the next phone call is about someone's carotid, and you're dealing with all aspects of the body, all different vascular beds, and it's very rewarding. What I think I like the most about vascular surgery is you still have to be a doctor in a way. You follow a lot of our patients, we follow them longitudinally. We develop a very close relationship with them, not just as surgeons, but also as medical doctors working very closely with the primary care doctors, the cardiologists, the endocrinologists, the podiatrists. You're very much involved in the patient's long-term longitudinal care, 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 Doc Dog. 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. If you would like to provide feedback on this podcast or get more information when carotid artery disease or treatment options, send me an email, Debra schindler@medstar.net.