- Carotid Artery Angioplasty and Stent Placement
- Peripheral Arterial Disease
- Stroke / Endovascular Thrombectomy
- Uterine Fibroids
- Ask the Doctor (video)
Carotid Artery Angioplasty and Stent Placement
Narrowing of the carotid artery, one of the main arteries supplying blood flow to the brain, by plaque can lead to increased risk of TIAs and stroke and may result in small pieces of plaque breaking off and flowing into and blocking a major blood vessel in the brain. Angioplasty and stenting may be used in combination with thrombectomy to allow passage of the thrombectomy device into the brain in cases where the narrowing of the artery is too severe. The interventional radiologist can treat narrowing of the carotid artery by using a balloon to widen the artery followed by placement of a stent (a tiny mesh tube) to keep the artery open and prevent narrowing from redeveloping.
The carotid arteries are the main vessels supplying blood to the brain. Most individuals have one carotid artery on each side of the neck. The carotid arteries can become narrowed (stenosed) by atherosclerosis and fatty or calcified plaque, resulting in diminished blood flow to the brain. The brain has some ability to compensate for some degree of decreased blood flow, but if flow becomes decreased to a point that the blood vessels and brain tissue can no longer compensate for the decreased blood flow caused by the blockage, death of brain tissue can occur leading to a stroke.
- Stroke is the 2nd leading cause of death and 4th leading cause of disability worldwide. While in developed countries it is the leading cause of disability, 2nd leading cause of dementia, and 3rd leading cause of death
- 50% of survivors suffer permanent disability
- Carotid stenosis account for 25-30% of strokes
- Repair of blockage is typically recommended in patients with 70% blockage or greater and experiencing symptoms such as weakness, dizziness, or visual changes. While somewhat more controversial, most physicians will recommend repair in asymptomatic individuals with greater than 80% blockage
While traditional surgical repair of carotid blockage remains the preferred method of repair of carotid blockage in many individuals, carotid artery angioplasty and stenting has assumed a greater role in treatment of the disease, particularly in individuals who have increased risk with surgery or associated anesthesia or may have some unusual anatomy scarring from prior surgery that would increase the risks associated with the traditional surgical approach.
In carotid angioplasty, a small needle is placed into the artery at the top of the leg and a tiny angioplasty balloon attached to a plastic catheter is advanced under X-ray guidance to the level of the blockage in the carotid artery. The balloon is inflated for a short period of time. After the dilation, a second small catheter with a self-expanding stent is advanced to the blockage and deployed.
Risks associated with carotid stenting are considered similar to those associated with traditional surgery in the normal population and often decreased in those patients considered higher risk for surgery. To further prevent the risk of a small piece of plaque from breaking loose and reaching the brain, a special filter is placed above the blockage in the artery to trap any debris. Post procedure hospital stay is limited, typically one evening. Patients may resume normal daily activities nearly immediately and are typically maintained on mild blood-thinning medications like aspirin or Plavix for a number of months post procedure to further decrease risk of any clot formation following treatment.
Stroke / Endovascular Thrombectomy
A stroke occurs when blood flow to a portion of the brain is interrupted or there is bleeding into the brain and the tissue in that area of the brain begins to die, resulting in sudden symptoms and neurologic impairment. Often referred to as a “brain attack” a stroke is the neurologic equivalent of a heart attack. Every year, more than 800,000 people experience a stroke, with almost 90% of strokes being “ischemic” and related to interruption in blood flow either due to blockage of the carotid artery in the neck or due to a clot escaping the heart or other vessels and lodging in an artery in the brain.
A stroke is a medical emergency and the fifth leading cause of death in the United States. Prompt treatment is critical in an attempt to save brain tissue and minimize long-term damage. Early symptoms may include:
- Weakness of the facial muscles or limbs
- Numbness or tingling
- Trouble speaking
- Severe headache
Some patients may initially show signs of a “mini-stroke” or transient cerebral ischemic attack (TIA), with symptoms that may resolve in a few days or within a day. TIA may be a strong predictor of impending stroke and should not be ignored; rather it should immediately be brought to the attention of your medical provider.
When stroke occurs, minutes matter. Restoration of adequate flow to the brain tissue provides the best opportunity to prevent death and limit long-term disability.
Through a tiny incision in the skin of the leg, an interventional radiologist can precisely navigate special catheters under X-ray guidance to the level of the blocked artery. A stent-like device can be utilized to remove the clot and to restore blood flow to the part of the brain that is not receiving blood due to blockage by the clot. The faster this blood flow is restored, the better the chances for good recovery from the stroke.
Uterine fibroid, a type of tumor in the uterus that is very typically benign, arises from the muscle tissue layer that surrounds the uterus. Fibroids may affect of 70-80% of all women in the United States before they are 50 years old and can present with a variety of symptoms that include:
- Uterine pressure or pain
- Heavy menstrual bleeding or cramps
- Pain during or following intercourse
- Leg pain
- Urge to urinate frequently
Some women will have one large dominant fibroid, while others may have multiple smaller fibroids that together lead to symptoms. If symptoms are suggestive of fibroid problems, ultrasound and MRI will often be ordered to confirm the diagnosis and define tumors that require treatment. Not all patients with fibroids will be candidates for UFE, but for those who are appropriate candidates, the procedure may provide a desirable alternative to traditional surgical hysterectomy.
Fibroids require significant blood flow from the blood vessels that supply the uterus to grow, and by limiting blood flow with Uterine Artery Embolization (UAE), the fibroids may greatly reduce in size with marked improvement in symptoms in over 90% of women.
During UAE. the interventional radiologist may guide a small plastic catheter into the specific blood vessels that supply the uterus and fibroid, utilizing X-ray guidance. Once in position, tiny particles are injected under X-ray control to block the vessels feeding the fibroid and starve it of flow and associated nutrients, resulting in shrinkage of the benign tumor. When embolization is felt to be adequate, the catheter is removed and a small bandage placed.
Most patients are kept overnight to allow for treatment of immediate cramping and discomfort that may occur after the procedure. Some discomfort may continue for a few days up to a week, including possible low-grade fever as the benign fibroid tumors die and shrink. Risk of infection is very small but is observed, and you may also be treated with antibiotics following the procedure as a precaution.
Ask the Doctor
Our very own Dr. Mehall was shown on the local Ask the Doctor show along with a few other members of the UPHS Neuroscience team discussing Brain and Stroke Issues. Great topics and discussions included Aneurysms, Brain Tumors, Dementia, Parkinson’s, along with Carotid Stenosis, Spinal Stenosis and Treatment of Chronic Neck and Back pain.
Peripheral Arterial Disease
Peripheral arterial disease (PAD) is a common disorder related to narrowing and blockage of blood vessels that lead to the extremities and is many times more common in the lower extremities. Blockages result in inadequate blood flow to the legs to keep up with demand for nutrients and oxygen during activity and, if severe enough, even at rest in bed at night. Decreased blood flow to the legs can lead to fatigue or weakness in the leg. One of the most common symptoms of advancing disease is cramping pain in the thigh or calf that develops while walking (claudication) and may resolve in a few minutes if standing still, only to recur when walking is resumed. Pain that occurs in the feet at night and resolves with hanging the feet over the side of the bed (rest pain) may be a sign of a particularly severe blockage that prevents adequate blood flow to the limb, even while resting. Such a severe degree of blockage can lead to skin breakdown (ulceration) and even death of the tissue in the area (gangrene). Some men may present to their doctor with impotence as the first sign of their arterial disease.
Peripheral vascular disease is typically caused by the buildup of fatty and calcified deposits (plaque) in the wall of the blood vessels supplying the leg and may be associated with blockages to the arteries that supply the brain and heart as well as the legs. PAD is strongly associated with smoking, diabetes and high blood pressure. Family history may play a role as well. PAD is more common in older individuals and is estimated to affect approximately 10% of Americans.
Some patients who present with symptoms such as claudication may be able to make simple lifestyle modifications, such as smoking cessation, establishment of a regular and reasonable walking/exercise program, as well as treatment of underlying medical issues such as high blood pressure or diabetes. Diagnosis of PAD may be established by your physician by medical history and physical exam, often combined with assessment of blood flow with ultrasound examination or CT scan.
For patients with more advanced blockage of PAD that does not respond to medical treatment, several options may be available. Surgical bypass is a well-established procedure to surgically position and implant a small fabric tube across the area of blockage to redirect blood flow around the blockage and restore adequate flow to the leg. However, not all patients will be candidates for surgical repair due to health issues that may increase risks and complications. Recovery times required following surgery, as well as additional risk factors may make a minimally invasive approach to resolving the blockage much more attractive.
Angioplasty with stenting involves placement of a small plastic catheter into the blocked artery through a small needle hole in the skin of the arm or leg. The balloon catheter is advanced to the blockage under X-ray guidance and inflated for a period of time and then deflated. The small metal mesh stent can then be advanced through or with the same catheter and deployed to maintain the vessel and prevent reformation of the blockage.
Percutaneous atherectomy may be used in combination with angioplasty and stenting, particularly in small blood vessels further down the leg or when plaque buildup is excessive and may not allow initial passage or inflation of a balloon catheter. During atherectomy a small catheter with a fine cutting edge is advanced to the blockage and activated, trimming and removing obstructing plaque while simultaneously applying suction to the catheter to remove plaque.