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Karotis Artery Disorders

Patients who have astroke or are at high risk of stroke are first evaluated and followed up by neurologists.
Your neurologist will perform some tests on you (Doppler USG, Brain-Neck CT-Angiography or MR-Angiography).

One of the most common causes of stroke is plaques in the carotid arteries (carotis artery). If the stenosis caused by these plaques is serious, it may disrupt the nutrition of the brain tissue on the same side and lead to some complaints in the patient.

Patients with severe stenosis in the carotid arteries are referred to a cardiovascular surgeon for further examination and treatment.


What is a carotid artery, where are they located and why are they important?

Brain tissue receives the clean blood it needs to perform its normal functions through four arteries.
Two of these arteries, which feed from the aortic arch, travel to the right of our neck and the other two to the left, leading to the brain (see the figure).

Tablo 1: Arteries responsible for feeding the brain
SCA: subclavian arteries, VA: vertebral arteries, CCA: common carotid arteries
ICA: internal carotid arteries, ECA: external carotid arteries

i. Internal carotid arteries (ICA):

- Internal carotid arteries are the major branches of the common carotid arteries (carotid arteries) (CCA) that feed the brain.
- It enters the skull by looking upwards from both front/side of the neck.
- Internal carotid arteries feed the anterior and middle parts of the cerebral hemisphere and the retinal layer of the eye on the same side of the skull.
- The internal carotid arteries carry fresh blood to 70% of the brain tissue.
- External carotid arteries (ECA) are the other main branch of the common carotid arteries and they give branches that feed the face, neck and scalp on the same side, they have nothing to do with the nutrition of brain tissue.
ii. Vertebral arteries (VA):
- The vertebral arteries are branches that emerge from the arm arteries (subclavian arteries, SCA) leading to both arms and enter the skull by looking upwards from both posterior/lateral sides of the neck.
-The vertebral arteries feed the posterior parts of the brain, cerebellum and brain stem.
- The vertebral arteries provide blood supply to 30% of the brain tissue.
- The internal carotid arteries at the base of the brain and the branches of the vertebral arteries form connections with each other (Willis polygon). Thanks to these connections, the continuity of brain circulation is tried to be ensured in case of blockage in any vessel.

Why is it important to have plaque that causes stenosis in the carotid arteries?

The tolerance of brain tissue to lack of oxygen is so weak that brain cells that have been deprived of oxygen for more than four minutes begin to die irreversibly. Therefore, stenosis or blockages in the carotid arteries, which carry clean blood to our brain, can lead to temporary or permanent neurological disorders in the relevant parts of the brain.

The presence of plaques in the carotid arteries puts the patient at risk of stroke. Because a clot that will sit on a crack or tear in this cholesterol plaque may cause the patient to have a stroke by suddenly interrupting the blood flow in the already narrowed vein. (See the figure on the side).

How is the decision taken to intervene in the stenosis in the carotid arteries?

There are three treatment methods in the treatment of patients with carotid stenosis: drug treatment, treatment with non-surgical (endovascular) intervention and treatment with surgery (carotid endarterectomy).
Non-surgical and surgical treatment methods are complementary rather than alternative to each other.
A board was established in our hospital to assist patients with carotid artery stenosis in making decisions in the advanced diagnosis and treatment phase. This board, which is called the "Yücelen Hospitals Heart Team", includes doctors who specialize in neurology, cardiovascular surgery, cardiology, anesthesia, internal medicine, chest diseases and radiology from time to time. The Heart Team, which evaluates all aspects of the patients brought to the board with a patient-focused approach instead of the disease, presents the most appropriate and most beneficial treatment method for its patients in the light of national and international guidelines. In this way, it aims to help the patient make a decision about his/her own treatment.

What is considered when deciding on the treatment method to be recommended to a patient with carotid artery stenosis?
The parameters considered when deciding on the treatment method to be recommended in a patient with carotid artery stenosis are as follows:
Complaints of the patient
Degree of stenosis caused by the plaque in the patient's carotid artery
Additional medical problems of the patient (do they have problems that increase the risk of the intervention to be planned?)

Characteristics of the patient's carotid artery such as its course, structure, width of the part after stenosis, etc.
Location and structure of the plaque causing stenosis in the patient (whether it is accessible by surgery, whether it is ulcerated, degree of calcification, etc.)

Whether the patient has concomitant coronary artery disease

How is Carotid Stenosis Surgery (Carotid Endarterectomy) Performed?

Since vascular stiffness is a systemic disorder, patients with stenosis in the carotid arteries are also likely to have stenosis in the coronary arteries. For this reason, all patients scheduled for carotid endarterectomy undergo detailed cardiological examination and coronary imaging before surgery.

In our hospital, surgeries for carotid stenosis are preferably performed under general anesthesia.
During carotid endarterectomy, the brain oxygenation levels of the patients are monitored instantly with the NIRS (Near Infrared Spectroscopy) monitor.

The jugular vein is found with a small incision made to the neck area where the jugular vein with stenosis is located, and the jugular vein and branches are clamped following the administration of blood thinner medication (heparin). Then, after the incision made to the carotid artery where there is stenosis, the plaque narrowing the vein is cleaned and blood flow is restored.

The operation takes 1-2 hours on average.
Patients are usually awakened in the operating room and separated from the ventilator.
If the patient does not need intensive care due to additional medical problems, he/she is taken to the service after surgery and discharged after 2-3 days.
Points to Consider for Patients with Carotid Artery Stenosis:
Absolutely stop smoking and tobacco use (regardless of the degree of stenosis)
Regular exercise
Healthy eating
Weight control ( patients are recommended to fall to normal body mass index)
Strict blood pressure monitoring (salt restriction and use of blood pressure medication if necessary)
Strict sugar control (diet and use of sugar-lowering drugs if necessary)
Use of diet/cholesterol medication to keep LDL cholesterol (bad cholesterol) levels below 100 mg/dl
Regular use of blood thinners recommended to the patient for a long time
Regular visits to the outpatient clinic

What Is Regular Exercise?

According to the recommendations of AHA (American Heart Association), the intention of preventive exercises from cardiovascular diseases is:
a. 30 minutes of moderate exercise 5 days a week (150 min/week)
Examples of moderate-intensity exercises:
Brisk walking
Cycling (slower than 16 km/h)
Taking care of gardening
Playing tennis (as a team)
Salon dances
b. 25 minutes of vigorous exercise 3 days a week (75 min/week)
Examples of vigorous exercises:
Climbing uphill or walking at a fast pace
Cycling (faster than 16 km/h)
Taking care of heavy gardening works (hoeing, digging, etc.)
Playing tennis (singles)
Aerobic dance

What is meant by healthy eating?
Consumed foods are meant to be rich in fruits, vegetables, unground grains, legumes and nuts, moderate in low-fat dairy products and seafood, and poor in processed meat products, sweetened beverages, salt and processed grains.

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