(November 25, 2008 - Insidermedicine) On a recent trip to Boston, we caught up with Dr. Michael Jaff, DO, who is an Associate Professor of Medicine at Harvard Medical School, and the Medical Director of the Vascular Center at Massachusetts General Hospital Heart Center. Dr. Jaff's research focuses partly on the safety and durability of endovascular devices (predominantly stents) used as therapy for peripheral vascular diseases.
If I had a bruit in my neck…
If I had a bruit in my neck, what would I do. First of all, I would define what a bruit is: a bruit is an abnormal sound that a doctor or a caregiver hears with a stethoscope. That sound suggests turbulence or changes in blood flow. It might mean that there’s a narrowing in that artery. Specifically, when you listen in the neck the artery that we worry most about is the internal carotid artery, the main artery that takes blood directly from the heart to the brain. So if that’s heard, the first thing I would do would be to get a carotid duplex ultrasound exam, a simple, painless, non-invasive test using Doppler imaging, which detects speeds of blood flow. The faster the speed of blood flow, the more narrow the artery. The second thing I would do is remember that hearing a bruit in the neck automatically signifies increased risk of heart artery disease, so I would speak to my doctor about my risks for potentially having heart-artery disease and if I had risk factors that weren’t effectively being treated, I would suggest that they be treated. Based on the results of the carotid duplex ultrasound, I would then determine what would be the next step. If there weren’t blockage then it is a sound heard from other things as well (eg thyroid gland, veins) – things that aren’t worrisome. If there is blockage but it is not severe, then I would aggressively treat risk factors to lower the risk of that progressing and getting worse. If it were severe, I would ask to be seen by a specialist in vascular disease who could help determine what the appropriate therapy might be.
What are the risks of carotid artery stenosis?
The risk based on carotid artery stenosis is largely based on how severe the narrowing or stenosis might be. If it is greater than 70 or 80%, the risk of having a stroke is significantly increased over the same patient who doesn’t have that degree of blockage. So that would be the greatest concern. But in addition finding that narrowing in the carotid artery also signifies the potential for artery disease in other arteries as well, like the heart, legs, kidneys, etc, and so we always think about that. Certainly a severe stenosis in a carotid artery warrants at least more aggressive medical therapy to prevent progression or worsening of that blockage, and maybe even a procedure to reduce the amount of blockage that’s there.
What treatment options are available?
The treatment options for carotid artery blockage depend on how severe the blockage is, so we’ll start off with patients with some blockage, but for whom it doesn’t reach 50%. In those patients, the treatment is entirely medical, and that means that the cholesterol, blood pressure, blood sugar, smoking issues are all addressed so that we lower the risk of that going from less than 50% to greater than 50%. In patients who have a greater than 50% blockage and who have been unfortunate enough to have a symptom already from that like a transient episode of blindness, trouble getting the words out that one would want to say, weakness or numbness of an arm or a leg, those patients clearly need to have a procedure to reduce that blockage. That procedure might either be a surgical procedure in which the artery is opened and the plaque removed, or a stent procedure in which the stent is placed directly inside the artery to alleviate the blockage. If the blockage is more severe (greater than 70 or 80%) even if the patient has never had a warning sign or symptom from it, many physicians will consider that procedure, either surgery or stent, to lower that blockage risk.