Narrowing of the arteries can also occur in the neck, in the vessels that feed the brain. Usually due to atherosclerosis, carotid or vertebral artery stenosis can be a risk factor for future stroke. For certain patients with carotid or vertebral artery stenosis, endovascular revascularization can be performed with angioplasty and stenting, combined with use of a 'cerebral protection device' to prevent debris from traveling downstream into the brain.
Atherosclerosis is the most common of several causes of arterial narrowing in the neck. As with arterial stenosis in the brain, any narrowing reduces blood flow to the brain and increases the risk of future stroke.
Carotid Stenting vs. Surgery
The mainstay of treatment for the carotid arteries has been a surgical procedure called carotid endarterectomy. Endovascular repair with angioplasty and stenting is a more recent development. Currently, endarterectomy is appropriate treatment for carotid stenosis for those patients with significant narrowing and low surgical risk. However, for those patients who have certain risk factors, including age, active heart disease, or previous carotid surgery, the complication rate of endarterectomy goes up.
For these patients, we can offer an alternative treatment. Carotid angioplasty and stenting is an appropriate treatment for patients at high risk for carotid endarterectomy. As in the brain, a balloon is passed over a wire into the narrowed artery inflated to widen the narrowed segment. After the angioplasty is performed, a metallic stent is placed to prevent recurrence of the narrowing. The procedure is performed with a cerebral protection device — essentially a mesh basket that is placed ‘downstream’ from the atherosclerotic plaque in the neck — to catch any bits of plaque that break off during treatment to reduce the risk of stroke.
Vertebral & Subclavian Disease
For the vertebral arteries and the subclavian arteries, treatment with angioplasty alone or angioplasty and stenting can be appropriate first line therapy, even in patients who are not considered high surgical risk.
Although many practitioners offer stenting, we feel that the best outcomes occur with operators who have experience with the cerebral vasculature and stroke therapy. At Maimonides, Interventional Neuroradiology is the primary provider of stroke therapy and carotid stenting. We are also actively involved in several studies to further the development of this technology.