Q&A: Avoiding the silent danger of carotid artery stenosis (CAS)

Carotid artery stenosis: Protect patients from a "silent killer"

Carotid artery stenosis (CAS) is one of the “silent killers” in the heart and vascular world. It’s a leading cause of stroke in the U.S., but it’s often asymptomatic and may be less familiar to PCPs than other forms of atherosclerosis.

Shivik Patel, MD, and his fellow vascular surgeons at WellSpan Health see hundreds of CAS cases each year. They also offer a new treatment called transcarotid artery revascularization (TCAR), which is less invasive than other procedures and provides similar protection against stroke. The first TCAR at WellSpan Health occurred in 2022, when the procedure was FDA-approved for standard-risk patients, and the 200th was this past spring.

Below, Dr. Patel answers common questions about CAS and explains how PCPs can help detect this condition and related types of atherosclerosis.

Shivik Patel, MD

What is the relationship between CAS and peripheral artery disease (PAD)?

Both result from atherosclerosis: PAD occurs in the legs, and CAS in the neck, which is why the risk of stroke is so high. But many clinicians aren’t aware that CAS often develops before PAD. Generally, blockages tend to appear near the heart first, then in the carotid arteries, and finally in the legs.

If you have a patient with known blockages in the legs, they should have their carotid arteries evaluated. There’s a high likelihood they have an obstruction there but don’t know it.

How do you diagnose and treat CAS?

We confirm this condition with a 30-minute ultrasound. It’s non-invasive and shows me everything I need to make a diagnosis.

• If the artery is more than 70% obstructed, the patient may need surgery. In that case, I order a CT scan so I can plan the procedure.
• For patients with no symptoms and obstructions below 70%, it’s best to manage it medically. Statins and antiplatelet medication can slow the progression and help many patients avoid surgery.

What is transcarotid artery revascularization (TCAR)?

TCAR is a new method for inserting a stent in a carotid artery to improve blood flow. The previous method gains venous access through the femoral vein, in the groin, and direct carotid access via a small neck incision. Stenting is then performed through the neck while blood flow is temporarily reversed and filtered to decrease stroke risk. TCAR works similarly, but it requires one incision instead of two. The stenting and blood flow reversal all take place via vessels in the neck.

TCAR also has some advantages over carotid endarterectomy (CEA), which is when we peel back the artery and remove the plaque. The two treatments haven’t been tested against each other for safety and efficacy. But on its own, TCAR has a strong record of avoiding stroke during the procedure and durability afterward. In practice, the incision size, procedure time and pain are all reduced compared to CEA.

Which patients are eligible for TCAR?

The best candidates are patients with:

• Focal lesions that are short and have no soft features. Soft features mean a clot, and a stent can push clots forward. CEA is better for patients with soft features.
• Low obstruction in the vertebral arteries. TCAR involves clamping the carotid artery where I’m adding the stent. Blood from that artery is directed away from the brain and filtered during the procedure, to remove any loose plaque. During that process, the brain relies on the remaining carotid and vertebral arteries to supply the blood it needs. If those arteries are obstructed, then TCAR isn’t a good option. In those patients I’d consider transfemoral carotid stenting instead.

I developed these criteria in collaboration with my neurosurgery and cardiology colleagues using an evidence-based, best practice approach. Ultimately, we treat every patient as an individual and select the best treatment option based on their anatomy.