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Posts Tagged ‘stroke prevention’

Here at Cartagena Surgery, we like to bring uplifting news every once in a while.. For all my devoted drinkers of coffee, here’s some more encouragement.
There are some problems over at wordpress so my page won’t be as pretty with links today..

Coffee may lower risk of Prostate cancer

Since we’re equal opportunity types, here’s another article for the ladies..

Coffee may lower risk of breast cancer

of course, this is all preliminary, so we need more research before we say anything definite – but in the meantime, stop feeling guilty and have another cup.. (notice – I did not say Starbucks double mocha latte – that just doesn’t count..)

Of course, with the recent rains in Colombia, coffee may be just a little more precious this year.

https://cartagenasurgery.wordpress.com/2011/03/13/more-good-news-for-coffee-drinkers/

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So your doctor (or nurse practitioner / physician assistant) ordered a carotid ultrasound, now what?

The ultrasound – carotid duplex

This is a great screening tool – to screen if you have blockages or not.  It doesn’t hurt, there is very little risk, it’s fairly quick and can be done almost everywhere.  (Really – sometimes you can get carotid ultrasounds at the mall during health screenings..)

If the results show carotid stenosis or elevated velocities suggesting stenosis of 70% or better – it’s decision time.  Now some test interpretations are a bit complicated – a lot of tests rate stenosis using ranges, and my least favorite range is 60-79% because it’s such a wide range at a point where 70-79% means possible surgical treatment yet 60-69% doesn’t.

** Some of my more proactive patients ask about surgery for lesser stenosis – such as 60% or even 40% – this really isn’t practical for a couple of reasons:

1.  a 60% may stay at that level of disease (particularly with medications) for a very long time

2.  The risk of stroke with this level of stenosis is much, much less than once a person crosses the 70-80% barrier, so the risk from surgery/ stenting may outweigh the risk of ‘watchful waiting’.  While surgical risk is low (we will talk about this later – it’s not zero – so taking additional risks when the stenosis is not severe is unwise.)

Additional Diagnostic Tests:

At this point it’s time to make a few preliminary decisions; if you absolutely do not want surgery – don’t bother with the additional tests.  We can prescribe medications using the information from the Ultrasound..

But – if you haven’t ruled out surgery – The CTA or MRA are essential!  These tests are more accurate – which is important for those people with ‘shoulder’ results (the 60-79% category) .

These tests also give surgeons a road map to work from. 

1. CTA 0r computerized tomography (CT scan) with angiography:

Most surgeons that I have worked with prefer the CTA over the MRA for surgical planning.  It’s less expensive, and the imaging is excellent for vascular structures.  Now a CTA includes contrast dye – usually in amounts that equal or exceed a cardiac cath (about 100ml) so people with kidney disease or risk for kidney complications either receive prophylaxis or an MRA. 

At a previous position, I developed CTA protocols to prevent contrast-induced kidney damage using criteria set forth by the international radiology community.

Special Procedure Orders

  This helped protect people at higher risk for complications – after all you shouldn’t develop problems from a test used to detect other problems..  But it made the test an all day procedure, so the patients could receive IV fluids and other medications.

According to the international radiology guidelines, the following individuals are at higher risk of developing complications:

– age greater than 75        – elevated BUN/Creatinine (kidney labs)*

-hx of chemotherapy/ radiation      – diabetes

-solitary kidney                                      -known kidney disease/ previous failure

– organ transplant hx                           -several other conditions (see protocol)

*usually creatinine greater than 1.2

I have attached the form for interested readers.

2. MRA – magnetic resonance angiography

this test is based on a MRI which gives much greater detail of soft tissue structures (not particularly needed for vascular surgery but good for other diagnoses).  This test uses a different dye which is less toxic to people with bad kidneys.  (However, if there is severe kidney disease or on dialysis – this dye has it’s own risks of complications.  For patients on dialysis, CTA is generally preferred – and the test is done the day before the regularly scheduled dialysis day.)

After the tests confirm that both: 1.) the stenosis is as severe as previously estimated on ultrasound  and 2.) the blockage is somewhere we can reach either surgically or in the lab –

It’s time to talk about treatment options.

Treatment options include: (and risk of stroke with each)

1. Do nothing (it’s always an option) – but for a blockage of 70-80% the risk of stroke is about 15% or 1 in 6.  This climbs to 25% for people with a history of stroke or TIAs.  Since I don’t have a crystal ball – I can’t tell people who will be that 1 in six.

2. Medical Management  (aka medications)  – medications are actually reasonable effective for many people.  Clopidogrel, ASA 81mg, and a statin drug are the usual drugs prescribed.  People with heart history should already be on most, if not all of these.  This has been reported in the literature to bring risk of stroke down to 8%

 (Of course, this is assuming that people actually take them regularly – and surprisingly, most people don’t/ won’t.)  The cost of the clopidogrel (plavix) is sometimes an issue for people, it is quite pricey.  There are statins available on the $4 formulary .  It’s also not a great choice for people with bleeding problems – previous bleeding strokes, bleeding ulcers or a history of falls.

3. Carotid Endartarectomy (CEA) – surgery to clean out the artery.  This requires a trip to the operating room, and often an overnight stay.  Surgery is actually fairly safe (we’ll discuss more at next post) even for the very elderly (proven safe for people in middle and late 90’s in several studies.  Surgery brings the risk of stroke down to about 1% (it’s slightly less than one percent but I rounded up to a full percent).  This risk of stroke is basically centered around the time of surgery (during surgery and first thirty days after).

4.  Carotid Stenting – this option was heralded (by the people doing it) as the second coming, and stents were placed in LOTS of people for flimsy reasons “patient refused surgery” (not mentioning that they scared the poop out of patients over surgery) yet research has failed to confirm the safety or efficacy of the procedure with the rate of stroke ranging from 7% to a full FIFTEEN percent in some studies.  (Now remember, for many people  – fifteen percent means they should have just stayed home/ picked option one.)  Now the interventionalists (the doctors who perform this procedure) are in big doo – doo because they have been misleading patients for several years, or overplaying (vastly) the risks and fears of surgery and downplaying the risks with stents..

We will talk more about the last two options in the next post..

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