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Is it necessary to got for angiogram with stent placement for blockage in artery?

DOCTOR OF THE MONTH - May 2014
May 2014
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Radiologist
Practicing since : 2002
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Don't know if you can see my existing post (which has been closed)--it contains a lot of the background info for my next question. Had Carotid Doppler which showed some blockage in artery. Subsequently, had CT with contrast which confirmed narrowing in the left carotid artery. Doctor has proposed angiogram with stent placement or endarterectomy. From our conversation, I got the impression that he was recommending stent placement over endarterectomy. However, what I'm finding on the web indicates that the endarterectomy is the first choice of doctors and that stent placement would only be done if the patient was too ill for the surgery. Can you help clarify pros/cons of each?
Posted Sun, 9 Feb 2014 in Medicines and Side Effects
 
 
Answered by Dr. Vivek Chail 1 hour later
Brief Answer: Please find detailed answer below Detailed Answer: Hi XXXX, Thanks for writing in to us. I have read through your query in detail. Carotid artery stenting and endarterectomy are two of the popular treatment options available to patients like you. Lots of research has been done and I would like to share the latest reliable research medical literature available. The latest study concludes and I quote "Hemodynamic depression occurs more often after carotid artery stenting and severe hypertension more often after carotid endarterectomy, but these complications are not responsible for the excess of major perioperative events after carotid artery stenting." Therefore the primary concern regarding endarterectomy being the first choice among treating doctors is clear. Further it is seen that Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are frequently complicated by hemodynamic instability due to manipulation of the carotid sinus. In some observational studies, hemodynamic depression after CAS has been associated with an increased risk of stroke, myocardial infarction (MI), or death. Randomized trials have consistently shown that CAS is associated with a significantly higher rate of stroke or death within 30 days of treatment than CEA. The extent to which this excess is attributable to hemodynamic depression after CAS is uncertain. Arterial hypertension after CEA and CAS has also been associated with the cerebral hyperperfusion syndrome (CHS), stroke, or death." Link to article is given below: WWW.WWWW.WW Hope your query is answered. Do write back if you have any doubts. Wishing you good health. Regards, Dr.Vivek
Above answer was peer-reviewed by
 
Follow-up: Is it necessary to got for angiogram with stent placement for blockage in artery? 38 hours later
Thank you, Dr. XXXXXXX At what % of blockage of the carotid artery would you recommend either CAS or CAE versus resolving with meds, lifestyle changes, etc. In other words, if the blockage is less than X, you would recommend holding off on procedures and focusing on healthy living and meds. I don't know my % of blockage (will find out Mon or Tues), but the vascular surgeon said some people go their whole life with narrowed arteries and don't have any symptoms. He didn't seem to feel there was a rush on it and said it was my call. If I delayed; however, and the narrowing worsened, he said we may lose out on the chance to do the stent (which after everything I've read--including what you wrote, doesn't sound like a bad thing) and/or I would be putting myself at risk for a stroke (which it sounds like I am at risk for that regardless of which procedure I choose). I'd prefer to take the more conservative action--assuming I am not putting my self in jeopardy or exposing myself to added risk. Thank you. Sorry. One more question. Doctor has ordered an angiogram with possible stent placement. Why would an angiogram be required after I have already had a CT with contrast (angioplasty)? What would the CT angioplasty show that the angiogram wouldn't.
 
 
Answered by Dr. Vivek Chail 5 hours later
Brief Answer: Please find detailed answer below Detailed Answer: Hi XXXX, Thanks for writing back with an update. If the patient is symptomatic and X is more than 70% then CAE or CAS is advised, and if asymptomatic and stenosis more than 80%. With lesser stenosis, the patient can be put on medications and lifestyle changes with regular follow up. I think the stenosis is less than 70% and therefore your vascular surgeon is allowing you to take a call. Further, the risk as you know persists but it is a relative risk and not absolute as your doctor has pointed out. However the risk can be controlled and decreased by taking medications. You may get follow up carotid Doppler which will show treatment response to medications. Angiogram (conventional) is a diagnostic and therapeutic procedure. CT angiogram is only a diagnostic procedure. Probably your doctor wants to see the flow and turbulence at the site of stenosis. This is not seen on CT angiogram. The possible stent placement is a routine practice while ordering an angiogram. It is a decision taken by the doctor at the time of angiogram whether to put a stent and open the stenosis. Note: Angioplasty is term used to open up a narrowed segment of artery by inflating a balloon in the lumen. Angiography/ angiogram is the term used to see the arteries (usually by injecting contrast material). Hope your query is answered. Do write back if you have any doubts. Wishing you good health. Regards, Dr.Vivek
Above answer was peer-reviewed by
 
Follow-up: Is it necessary to got for angiogram with stent placement for blockage in artery? 5 hours later
Again, thank you, Dr. XXXXXXX Can you also tell me which meds are commonly prescribed to reduce/eliminate plaque? Also, can plaque be eliminated or does it always remain?
 
 
Answered by Dr. Vivek Chail 49 minutes later
Brief Answer: Please find detailed answer below Detailed Answer: Hi XXXX, Thanks for writing back with an update. Antiplatelet agents like Aspirin, Ticlopidine and Clopidogrel can be prescribed. Anticoagulation agents like Warfarin (titrated international normalized ratio [INR] 2–3) use in patients with noncardiac emboli is controversial. The eliminations of plaque is a very slow process and may require regular monitoring. Your lipid profile test results are important and if they are above normal, anti lipid medications need to be taken. Hope your query is answered. Do write back if you have any doubts. Wishing you good health. Regards, Dr.Vivek
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