Question: I have a dear friend who has just had stent surgery on her 90%-closed left carotid artery. The doctor told her he could do nothing to help her 100%-closed right carotid. If the left one can be treated at 90%, why can't the right be treated at 100%?
Dr. Hibberd's Answer:
It can be re-opened, but tends to close up again. Ultimately, there’s all of the risk with no benefit. The procedure involved in placing a stent through a chronically occluded carotid has been associated with increased incidence of stroke.
Complete carotid occlusion is usually managed by open surgical procedure called endarterectomy. The device used to open the occlusion without surgery using a catheter often sends a shower of microfragments to lodge in multiple areas of the brain, resulting in an embolic stroke. Occasionally the procedure is chosen to open a chronically occluded carotid, but the results are almost always uniformly poor.
It is not usually wise to subject both carotids to surgical procedure at the same time especially when one has been occluded for a long period of time. For obvious reasons, we try to minimize activating the body's clotting and coagulation systems during surgery on blood vessels.
I understand your dilemma, and I have often been the attending physician asking the same question to my neurosurgical, cardiac, and vascular consultants on behalf of patients in similar situations.
Though it sounds logical to open the closed vessel, repeated clinical experience and literature review shows no practical benefit to re-opening a carotid artery that has been occluded for a long period of time. Many trials have shown that when patients with chronic total occlusion of carotid artery were surgically re-opened and subsequently restudied, almost all of them had re-occluded their carotid vessel. This re-occlusion usually occurred within days, if not weeks, with no benefits.
As doctors, we are always looking for the exception, but the usual result of reopening a chronically blocked carotid artery is re-occlusion and perhaps increased incidence of embolic stroke.
The early reopening of occluded coronary arteries, however, is a very different matter. It is lifesaving and is the basis for all current stroke and heart attack management strategies we use today. The benefits seen with acute intervention are time sensitive (meaning hours not days). It saves lives, saves brain and heart tissue from permanent damage, and helps preserve normal function.
Any blood vessel that becomes acutely occluded, meaning it has just happened within hours, is almost always able to be successfully reopened. This is life-saving in the case of carotid or coronary artery occlusions.
Generally, the effort to reopen a chronically-blocked artery is futile and involves excessive risk UNLESS the occlusion is fresh. Acute, fresh occlusions ARE worthwhile opening immediately.
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