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Preventing Strokes With Vascular Surgery

Published in Heart & Vascular, For the Health of It Author: Vascular Surgeon Christopher Leville, MD

While you may be familiar with heart disease and coronary blockages caused by plaque buildup, carotid artery disease is not as well-known. Most people don’t know they have carotid artery disease until they have a stroke. Vascular Surgeon Christopher Leville, MD, answers questions about vascular surgery, stroke and a new procedure called TCAR (transcarotid artery revascularization).

Question: What is vascular surgery?

Dr. Leville explains TCAR at the Surgery Open House.
Dr. Leville explains TCAR at the Surgery Open House.
Dr. Christopher Leville: I like to tell people it’s essentially everything outside the heart and the brain with regards to artery and vein disease.

At CentraCare, we have multiple specialties that take care of vascular issues such as neuro, radiology or neurointerventional, who do stroke care. We have cardiac surgery and cardiology, vascular surgery and intervention radiology. We do the majority of carotid surgery at CentraCare. And so that’s a very exciting thing because of this new procedure we have to offer.

Question: What would be the reason for doing surgery on the carotid artery?

Dr. Christopher Leville: The number one reason is to prevent stroke. Blockages of the carotid artery are still the number one cause of stroke in the United States.

Question: What can we do to not to see you?

Dr. Christopher Leville: That has to do with general health issues such as smoking cessation, blood pressure, cholesterol control, diabetes — all of the same things that affect heart disease can affect stroke care and carotid surgery.

Question: What are the screenings or tests for vascular disease?

Dr. Christopher Leville: If patients have symptoms of stroke, whether they’ve had previous stroke or transient symptoms, those are obvious things that need carotid artery ultrasound or further imaging. But, also, if they have other significant medical problems with cardiac history or peripheral vascular history, we look for carotid disease. For the most part, a lot of it is preventative.

Question: What are TIA strokes?

Dr. Christopher Leville: Those are transient ischemic attacks, and they are stroke symptoms that usually resolve in less than 24 hours. That’s because the stroke is so small that the circulation in the brain does not really detect that there is a stroke that’s occurred.

You will still have symptoms: the facial droop, difficulty with speech, clumsiness of the hand or some other type of motor dysfunction. And it’s usually on one side.

Question: Are TIA strokes still serious?

Dr. Christopher Leville: Yes, it can be scary and that’s why education for the community is important because when their symptoms resolve, patients think that, “Oh, it’s gone away. I don’t have to worry.” But it is an indication for future problems. We know that patients who have TIA are much more likely to have more if they’re not treated properly.

Question: What is the new TCAR procedure?

Dr. Christopher Leville: It’s an exciting, hybrid type surgery that we started doing over a year ago at St. Cloud Hospital, and it gives another option for treatment of the carotid artery blockage. Instead of a standard surgery, which is a long incision along the neck to clean out the artery, we actually make a smaller incision above the collarbone. And then, we have a device that actually puts the flow of the carotid artery in reverse so that no debris can break off to the brain while we put a stent across the blockage of the artery.

Traditional carotid stenting is still very much needed, but usually for those procedures, you have to have some type of device beyond the blockage such as a filter. And with that option, the stroke rate is still around 3%. Perhaps a carotid surgery is slightly lower, perhaps 1.5-2% risk of stroke from the surgery. But what’s exciting about TCAR is, both the national and the data from St. Cloud Hospital show that the stroke rate is approximately 1-1.4%.

I was skeptical when it first became available, but there’s been a lot of good national data, and there was a recent article in the Journal of American Medical Association that’s proving that as well, with thousands of patients being treated.

Question: How is the TCAR procedure performed?

Dr. Christopher Leville: We have fluoroscopy, so we have a large X-ray machine that we’re watching the procedure on as we’re doing it. Then we do the small incision to get to the carotid artery. The smaller incision decreases nerve injury and decreases stress on the heart, since heart attack is more common with carotid surgery than it is with stenting. That’s what’s exciting about the newer procedures because as vascular surgeons, we really are able to offer this hybrid approach among other, different options to patients.

Question: St. Cloud Hospital is a regional center for this particular surgery, being the busiest in the state of Minnesota. Why is that?

Dr. Christopher Leville: I think it owes a lot to our multiple specialties and our stroke center. In 2018, there were 260 carotid procedures done at St. Cloud Hospital. More than half of them are carotid endarterectomy. But still a significant amount is carotid stenting as well. And carotid stenting is exciting because we do that with our stroke team and our neurointerventional team for the more acute cases with clots and patients who come in, and they get a stent right away and we fix everything immediately.

Question: What are other procedures that you perform?

Dr. Christopher Leville: We treat most aortic disease of people with abdominal aneurysm, which is very common. We also treat thoracic aortic disease and peripheral artery disease of the lower extremities, which is a very common cause of limb loss. We do a lot of procedures which are mostly now minimally invasive, meaning no major incisions. We’re able to open blocked arteries and treat aneurysms with different types of stents.

Question: How do we know that an aneurysm might occur?

Dr. Christopher Leville: Well, that’s the difficult part because there is actual screening now for an abdominal aneurysm that is Medicare approved. But there are no warning signs. If someone has a history of smoking or family history of aneurysm, they would be able to be screened at age 55. That’s why that’s usually when we detect those types of aneurysms because people don’t have symptoms of a dominant aneurysm until/unless it ruptures.

Usually we treat a ruptured aneurysm with a stent procedure. We have stent devices that are on the shelf at the hospital that we can put in right away for an emergency, ruptured aneurysm.