Ask the Doctors

Dear Doctor: My cardiovascular surgeon tells me medicine has mostly abandoned shunt and stent placements as a solution to carotid artery plaques. Instead, doctors are returning to the older "Roto-Rooter" procedure because patient outcomes have proven less problematic. What's your take on this?

Dear Reader: Let's start with an anatomy lesson. The common carotid arteries are major suppliers of blood to the brain. You have two of them, and you can feel their pulse at the side of your neck, lateral to your Adam's apple (thyroid cartilage). They split in the neck to become the external and internal carotid arteries, which supply blood to the majority of the brain.

Turbulent blood flow at the location of these splits contributes to the formation of plaque within the internal carotid arteries, as do other factors like high blood pressure, diabetes and smoking. This plaque can rupture and cause closure of the artery; or a portion of the plaque can break off and lodge in a smaller artery. In either circumstance, a stroke occurs -- leading to a significant loss of neurologic function. Thus, if the internal carotid artery is significantly closed with plaque, it is necessary to clear the plaque.

What you describe as a Roto-Rooter procedure is called a carotid endarterectomy. A surgeon performs an endarterectomy via an incision in the neck. Taking care to maintain blood flow to that side of the brain, he or she clamps the internal carotid artery, makes an incision in the artery and locates the plaque. The surgeon then frees the plaque from the lining of the artery and removes it before closing the blood vessel and placing a patch on the artery to prevent complications.

Obviously, the procedure is not without its risks. The death rate from endarterectomy varies between 0.5 and 3 percent. Also, the rate of having a stroke during the procedure ranges between 0.25 and 3 percent and depends on how severe the plaque is and the skill and experience of the surgeon.

Carotid artery stenting is a different type of procedure in which the surgeon places a catheter into a major artery (usually the femoral artery in the groin), then moves it via wire up to the internal carotid artery. The surgeon then dilates the artery (if necessary) and lodges the stent into its lining.

On the surface, stenting may sound less dangerous, but studies have not found this to be the case. A 2012 analysis of 16 studies found that, in the 30 days after the procedure, stenting had a higher rate of combined death and stroke (8.2 percent) compared to endarterectomy (5 percent). A separate study also linked stenting to more minor strokes.

But note that the difference in death and major stroke was not seen among patients less than 70 years of age. And other studies have shown that, over timeframes of 4.2 and 10 years, the rates of major strokes and death show less of a benefit with the carotid endarterectomy versus stenting.

Still, as of now, research suggests that the carotid endarterectomy is clearly the better procedure, especially if you're over the age of 70.

But note that each patient is different. In difficult surgical situations, stenting remains a good alternative, and with newer carotid stenting techniques currently in development, the choices for individuals will continue to evolve.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.)

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