Ask Dr KK: When should one decide for carotid endarterectomy or removal of blockages with catheter?

It is indicated for selected medically stable patients with asymptomatic carotid stenosis of 60 to 99 % who have a life expectancy of at least five years, provided the perioperative risk of stroke and death is less than 3 percent. However, long-term outcomes for patients with carotid blockages managed by intensive medical therapy may be similar to surgical management. 

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK:What are the medical interventions for carotid blockages?

The interventions are management of hypertension, smoking cessation, use of statin drugs and low-dose aspirin.

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK: What is symptomatic carotid artery blockage?

Patients who have had a stroke or transient ischemic attack (mini paralysis) due to carotid stenosis are considered symptomatic and often benefit from carotid revascularization. Symptoms means transient or permanent focal neurologic symptoms related to the affected artery (same side loss of vision, opposite side weakness or numbness of an extremity or the face, difficulty in speech or loss of speech). Patients with nonspecific neurologic symptoms (dizziness or syncope/near syncope) are not considered in the definition of symptomatic carotid stenosis. 

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK: When to screen for carotid blockages?

Carotid duplex ultrasonography is not recommended for routine screening of asymptomatic patients who have no clinical manifestations of or risk factors for atherosclerosis. However one should screen asymptomatic individuals who have:

• Carotid bruit
•  Peripheral arterial disease
• Coronary disease
• Aortic aneurysm
•   Two or more risk factors for atherosclerotic disease.

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK: At what prevalence is screening beneficial?

Only at prevalence rates of over 20 % significant benefits are seen with at best about 100 strokes prevented for every 10,000 screened at 20 percent prevalence. Clinical features cannot identify asymptomatic individuals likely to have carotid stenosis. The annual risk of stroke in patients with asymptomatic carotid artery stenosis is relatively low. 

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK: How common is carotid artery blockages in general population?

The prevalence of carotid stenosis in general population is less than 1 %. Screening with resultant surgical procedures causes more strokes than it can prevent. For severe (≥70 %) carotid stenosis, the prevalence increases with age from approximately 0 to 3 %.

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK: How risky is carotid stenting or surgery?

Both endarterectomy and carotid stenting are associated with an increased 30-day risk of stroke and death. These are in the range of 2.3 to 3.7 percent for endarterectomy.

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK: How reliable is Doppler Carotid study for detecting blockages?

The reliability is variable and operator-dependent.

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK: What are the screening methods available?

1.    Carotid ultrasound followed by catheter angiography

2.    Carotid ultrasound followed by MRA

3.    Ultrasound alone

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.  

Ask Dr KK: Should I screen each patient for presence of carotid neck artery blockages?

The guideline says no. The potential harms include risks associated with the screening procedure itself like false positive findings leading to anxiety and the potential for unnecessary surgical procedures. Carotid angiography is associated with risk of neurological complications including stroke, with rates ranging from 0.1 to 1 %.

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association, Past Academic and Research Wing Head IMA, Chairman Ethics Committee Delhi Medical Council.