Carotid angioplasty and stenting, also known as Carotid Artery Stenting or CAS, is a minimally invasive, endovascular procedure used to treat carotid artery stenosis, which is a significant narrowing of the carotid arteries. These two major arteries, located on each side of your neck, are the primary highways that supply oxygen-rich blood to the large, front part of your brain. When these arteries become narrowed by a buildup of fatty plaque, a condition known as atherosclerosis, the risk of stroke increases dramatically.

Carotid angioplasty and stenting is a procedure designed to reopen this narrowed artery from the inside, restoring normal blood flow and stabilizing the plaque to prevent pieces from breaking off and traveling to the brain. The procedure is performed in a specialized catheterization laboratory by a team of experts, including an interventional neurologist, neuroradiologist, or vascular surgeon. It involves advancing a catheter from a blood vessel in the groin up to the neck, followed by the inflation of a small balloon to widen the artery and the placement of a tiny, mesh-like tube called a stent to keep it open permanently.

It is an important and less invasive alternative to traditional open surgery for many patients, offering a shorter recovery time and avoiding a large neck incision. This guide provides a comprehensive overview of carotid artery disease, the CAS procedure, its risks and benefits, and what you can expect from this life-saving intervention.

Understanding the Underlying Condition: Carotid Artery Stenosis

To understand the purpose of carotid stenting, it is crucial to understand the disease it treats and the serious threat it poses.

Anatomy and Function

The common carotid arteries run up each side of your neck. Near the jawline, each one divides into an internal and an external carotid artery. The external carotid arteries supply blood to your face and scalp, while the internal carotid arteries are responsible for supplying the majority of the blood to the cerebral hemispheres of your brain, which control thought, personality, speech, and motor and sensory functions.

The Process of Atherosclerosis

Carotid artery stenosis is caused by atherosclerosis, the same disease process that leads to heart attacks. Over many years, due to factors like high cholesterol, high blood pressure, and smoking, fatty deposits, cholesterol, and other cellular waste products build up in the inner lining of the artery, forming a substance called plaque. This plaque can gradually grow, causing the artery to become narrow and stiff.

How Carotid Stenosis Causes a Stroke

A significant blockage in a carotid artery can lead to a stroke in two main ways:

• Embolic Stroke (The Most Common Mechanism): The surface of the plaque is often rough and irregular. Small blood clots can form on this surface, or pieces of the plaque itself can break off. These tiny clots or debris, called emboli, are then carried upstream in the blood flow and can travel into the smaller arteries within the brain. There, they can become lodged, completely blocking blood flow to a specific area of the brain tissue. This deprivation of oxygen and nutrients causes the brain cells to die, resulting in an ischemic stroke.
• Thrombotic Stroke: In some cases, the plaque can grow so large that it severely reduces or completely blocks blood flow through the carotid artery itself, leading to a stroke.

A Transient Ischemic Attack TIA, often called a mini-stroke, is a critical warning sign. It occurs when a clot temporarily blocks an artery in the brain, causing stroke-like symptoms that resolve on their own, usually within minutes to hours. A TIA indicates a very high risk of a major, permanent stroke occurring soon after.

When is Carotid Angioplasty and Stenting Recommended?

The decision to treat carotid stenosis is based on the severity of the blockage and whether or not you have had symptoms like a TIA or a minor stroke.

For Symptomatic Patients

If you have experienced a TIA or a minor stroke and an imaging test confirms a severe narrowing of the carotid artery typically 70% or more, treatment is almost always recommended to prevent a future, more devastating stroke. The risk of a subsequent stroke is very high in the days and weeks following a TIA.

For Asymptomatic Patients

Many people are found to have a severe carotid blockage incidentally, without ever having had symptoms. In these cases, the decision to treat is more complex. Treatment may be recommended if the blockage is very severe, typically 80% or more and the patient is in good health, as the long-term risk of stroke may outweigh the risks of the procedure.

Carotid Stenting CAS vs. Carotid Endarterectomy CEA

For many decades, the gold standard treatment for carotid stenosis has been an open surgical procedure called Carotid Endarterectomy CEA. This involves a surgeon making an incision in the neck, opening the artery, and physically scraping out the plaque.

Carotid angioplasty and stenting CAS has emerged as a highly effective, less invasive alternative. The choice between CAS and CEA is a nuanced decision made by your medical team based on your specific situation. CAS is often preferred for patients who:

• Are considered at high surgical risk for open surgery due to other medical conditions like severe heart or lung disease.
• Have stenosis in a location that is difficult to access surgically.
• Have had previous neck surgery or radiation, which can create scar tissue.
• Have developed a re-narrowing of the artery after a previous CEA procedure.

What is Carotid Angioplasty and Stenting? The Technology

The CAS procedure is a multi-step process performed in a cath lab.

Angioplasty and Stenting

• Angioplasty: This is the process of widening the artery. A catheter with a small, deflated balloon at its tip is guided to the site of the narrowing. The balloon is then inflated, which compresses the plaque against the artery wall and stretches the artery open.
• Stenting: After the angioplasty, a stent is deployed. A stent is a small, expandable, wire-mesh tube that is placed inside the artery. It acts as a permanent scaffold, holding the artery open and preventing it from re-narrowing.

The Embolic Protection Device EPD

This is the most critical safety component of a modern CAS procedure. The primary risk during carotid stenting is that the manipulation of the plaque with the balloon and stent could cause small pieces to break off and travel to the brain, causing a stroke. An Embolic Protection Device is designed to prevent this.

• The Device: It is a tiny, filter-like or basket-like device that is attached to a guidewire.
• The Deployment: Before any angioplasty or stenting is performed, this device is carefully advanced through the catheter, past the blockage, and opened up in the artery downstream from the treatment area.
• The Function: It remains in place throughout the procedure, acting like a safety net. It allows blood to flow through but is designed to catch any plaque or clot debris that might be dislodged. At the very end of the procedure, after the stent is in place, the filter is collapsed back into a catheter and removed, taking all the captured debris with it.

Our Specialists

Carotid stenting is a highly advanced procedure that requires a specialist with extensive training and experience in endovascular techniques. This is typically performed by an interventional neurologist, interventional cardiologist, or vascular surgeon.

Dr. Rima Khanna

ADDITIONAL DIRECTOR & UNIT HEAD NEUROLOGY | Fortis Shalimar Bagh

Dr. Vikas Gupta

ADDITIONAL DIRECTOR NEUROLOGY | Fortis Jaipur

Dr. Pudukode Ramnath Krishnan

SENIOR CONSULTANT NEUROLOGY | Fortis BG Road

Patient Stories

"I had a mini-stroke TIA where the left side of my face went numb for about ten minutes. It was terrifying. The MRI and angiogram at Fortis showed a 90% blockage in my right carotid artery. My doctor explained that I was at very high risk for a major stroke. Because of some other health issues, my team recommended carotid stenting instead of open surgery. The procedure was done through my groin, and I was awake but sedated. The next day, I felt good, and a follow-up ultrasound showed the artery was wide open. That procedure gave me incredible peace of mind and very likely saved me from a massive stroke." - Sumit Saxena, 72, Gurugram

"During a routine health check, my doctor heard a noise called a bruit in my neck and ordered an ultrasound, which found a severe asymptomatic blockage. After a lot of discussion with my family and the vascular team at Fortis, we decided on a proactive stenting procedure. The team's explanation of the embolic protection device was very reassuring. Knowing that a safety net was in place made me feel much more confident. The recovery was very quick, and I was back to my normal routine in just a few days." - Sunita Verma, 68, Delhi

The Carotid Stenting Procedure: A Detailed Walkthrough

Preparation

• You will undergo a series of diagnostic tests, including a carotid ultrasound, CT angiogram, or MR angiogram, to map out the blockage.
• You will have pre-procedure blood tests.
• You will be started on antiplatelet medications like aspirin and clopidogrel for several days before the procedure to prevent blood clots.
• You must fast for six to eight hours before the procedure.

The Procedure in the Cath Lab

• Preparation and Sedation: You will lie on the procedure table. An IV line will be placed in your arm, and you will be connected to monitors. You will receive a mild sedative to help you relax, but you will be awake.
• Access: The doctor will numb an area in your groin with local anesthetic and insert a sheath into the femoral artery.
• Catheter Navigation: A guide catheter is advanced from the groin up to the carotid artery in the neck, guided by fluoroscopy.
• Embolic Protection: The embolic protection device is deployed in the artery above the blockage.
• Angioplasty: The balloon catheter is advanced across the blockage and gently inflated to widen the artery.
• Stent Placement: The balloon is removed, and a catheter carrying the collapsed stent is positioned. The stent is then deployed, expanding to press firmly against the artery walls.
• Completion: A final angiogram is performed to confirm that the stent is fully open and blood flow is restored. The embolic protection device and all catheters are then removed.
• Closure: The puncture site in the groin is closed, often with a special vascular closure device, and a pressure dressing is applied. The procedure typically takes one to two hours.

After the Procedure

• You will be taken to a recovery area or an ICU for close monitoring of your blood pressure and neurological status.
• You will need to lie flat for several hours to allow the groin access site to heal.
• Most patients stay in the hospital for one to two nights for observation.
• You will continue to take dual antiplatelet medications for at least a month, and likely one antiplatelet medication for life.

Myths vs Facts

Take the Next Step

Carotid artery stenosis is a serious condition that serves as a major warning sign for a future stroke. Fortunately, with modern medical and interventional therapies, we can effectively manage this risk and protect your brain health. Carotid angioplasty and stenting is a state-of-the-art, minimally invasive procedure that offers a safe and effective treatment option for many patients.

If you have been diagnosed with carotid artery disease or have experienced symptoms of a TIA, a timely and thorough evaluation by a neurovascular specialist is critical. Our multidisciplinary team is here to provide you with a comprehensive assessment, discuss all your treatment options, and deliver world-class care to safeguard your future.

CTA: Book a Neurology Consultation / Get a Second Opinion

Frequently Asked Questions

Q1. How long does the carotid stenting procedure take?

Ans. The procedure itself typically takes about one to two hours. However, you should plan for several hours in total, including preparation time before and recovery time immediately after the procedure.

Q2. Is the procedure painful?

Ans. The procedure is performed under local anesthesia and conscious sedation, so you should not feel any pain. You may feel some pressure at the groin site and a temporary, warm flushing sensation when the contrast dye is injected, but these are not painful.

Q3. What are the main risks of carotid stenting?

Ans. The most serious risk of the procedure is causing a stroke by dislodging plaque. The use of an embolic protection device is designed to minimize this risk significantly. Other risks include bleeding at the groin access site, an allergic reaction to the contrast dye, and a re-narrowing of the stent over time.

Q4. How long is the hospital stay?

Ans. For an elective carotid stenting procedure, the typical hospital stay is one to two nights for careful monitoring of your blood pressure and neurological function before you are discharged home.

Q5. When can I return to my normal activities?

Ans. Recovery is quite rapid. You will need to avoid strenuous activity and heavy lifting for about one week to allow the groin puncture site to heal fully. Most people can return to a desk job and light daily activities within a few days.

Q6. Will I be able to feel the stent in my neck?

Ans. No, you will not be able to feel the stent. It is a very small, flexible mesh tube located deep inside your neck, and it does not cause any sensation.

Q7. Why do I need to take blood thinners after the procedure?

Ans. Taking antiplatelet medications like aspirin and clopidogrel is absolutely essential after stenting. The stent is a foreign object, and these medications prevent blood clots from forming on its surface while the artery wall heals over it. Stopping these medications prematurely can lead to a sudden, catastrophic stent thrombosis.

Q8. How is my artery monitored after the procedure?

Ans. Your doctor will schedule regular follow-up appointments. This will typically include a carotid duplex ultrasound scan at regular intervals such as at 1 month, 6 months, and then annually to ensure that the stent remains wide open and that there is no significant re-narrowing.