Carotid Artery Disease

Q:  I read your column with interest and your article regarding carotid disease caught my attention. As a nurse clinician with 20 years of cardiovascular medical and surgical experience, I have a few concerns about the appropriate work-up.

The age of the patient is remarkable for the reported "100% blockage." It did not state the location of the stenosis... i.e., external or internal. Is this person Oriental -- as that population has a higher incidence of external carotid disease than western populations? If external in nature, the recommendation is not usually surgery, but if dilated aneursysmal carotid bulbs are involved the recommendation may change.

I have found that patients and families are capable of understanding this complex anatomy. Often they only hear numbers (i.e. X% blockage) and stop listening after the amount of blockage is mentioned. They need to know the description of the vessels... smooth, irregular, tortuous, ulcerative, and then will better understand the therapy recommended (e.g., aspirin, persantine, carotid angioplasty/stenting, surgical endarterectomy). Analogies to eddies in a stream, flow velocities of river beds, etc., are helpful in explaining the anatomy.

If severe internal carotid disease is present, then it is wise to get a baseline on that patient's coronary anatomy as three-vessel heart disease is seen in conjunction with severe carotid disease. It is rare to find isolated severe carotid disease with normal coronary arteries. Your mention of the possibility of Takayasu's arteritis is important to rule in or exclude.

I hope this patient's anatomy is clearly explained to them. If they continue to focus on "nothing can be done," an emotional toll begins to occur on the individual and on their relationship. They need to know what to be concerned about and how to co-exist with something that is "a bit different that the norm."

A:  Thank you for writing and explaining some of the technical details involved with carotid disease. For the sake of space and the general reader's interest and comprehension, I try to be brief and not as specific. Your point about having concurrent coronary artery disease is an important one.

"Dear Doctor" is a compilation of patient questions answered by doctors from the Medical College of Wisconsin.