Tuesday, July 10, 2007

Neurological Surgery Rounds and more!

This past week, I attended neurological surgery ICU rounds and the daily residents case conference where the residents discuss how each case should be handled for that day. During rounds, the residents assess neurological function by asking questions like the date, the patient’s name, the city, and asking the patients to wiggle their toes and lift their arms up. While the patients do not appear outwardly impaired, some of the patients are unable to perform these tasks and a few vary in their performance quite visibly from day to day. It is interesting to get a sense of what the patients are like outside of the angiography suite, where I spend most of my time, and the process going into deciding whether patients should be sent there or not.

Location of carotid artery and comparison of artery built up with plaque versus normal artery. www.vascularweb.org

I observed several procedures this week, including a carotid artery stenting procedure which is still in clinical trials to evaluate the effectiveness of CAS versus the standard of care – carotid endarterectomy (CEA) in preventing recurrent strokes. Many of you are probably wondering the same thing I was – stenting is such a common procedure, why is it still in clinical trials for this particular procedure? To answer this, first I’ll describe the standard of care for treating blockages of the carotid artery – carotid endarterectomy, then describe the carotid artery stenting procedure.

These procedures treat the problem of plaque building up in your carotid artery. This is particularly sensitive because the carotid artery supplies the head and neck with blood. Plaque buildup eventually causes less blood flow to reach the brain and allows for the possibility of part of the plaque or clots formed on the plaque breaking off and causing a stroke in your brain.

Image showing carotid endarterectomy, surgical treatment of carotid stenosis. www.vascularweb.org

The surgical treatment and standard of care for treating carotid plaque buildup – carotid endarterectomy involves temporarily blocking flow through the carotid artery and surgically removing the plaque from the inside lining of the artery.

Carotid artery stenting involves performing angiography to visualize the blocked artery. A balloon can then used to expand the artery and a stent is used to hold open the artery. Follow-up angiography is performed after stenting to assess the success of the procedure.

In the past there had been problems with the plaque breaking loose during the stenting procedure and causing a stroke upstream in the brain. As a result, a new system was developed that includes a device to catch plaque traveling upstream. In particular, in this study and as part of the CREST (Carotid Revascularization Endarterectomy versus Stenting Trial) study, Dr. Gobin is using the ACCULINK Carotid Stent System which includes a protection system that opens up to protect upstream arteries from embolic material, while still allowing blood to flow through.
Image showing carotid artery stenting. www.vascularweb.org

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