Stroke Prevention: Should I Have a Carotid Artery Procedure?

You may want to have a say in this decision, or you may simply want to follow your doctor's recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them.

Stroke Prevention: Should I Have a Carotid Artery Procedure?

1

Get the
Facts

2

Compare
Options

3

Your
Feelings

4

Your
Decision

5

Quiz
Yourself

6

Your Summary

Get the facts

Your options

Have a carotid artery procedure along with taking medicines and making healthy lifestyle changes to help prevent a stroke.
Don't have a procedure. Reduce stroke risk by taking medicines and having healthy habits.

Is this decision for you? This could be a decision for you if you have carotid artery stenosis but have not had a stroke or TIA. If you have already had a stroke or TIA, this information is not for you.

Key points to remember

Narrowing (stenosis) in a carotid artery increases your risk of stroke, so it's important to do what you can to lower your risk.
A carotid artery procedure may be an option if you have narrowing of 60% to 70% or more. A procedure is not an option if you have narrowing of less than 50%. You are less likely to get a carotid artery procedure if you do not have symptoms, regardless of the amount of narrowing.
Taking medicines and having healthy habits can help lower your risk of stroke. If you decide to have a procedure, medicines and healthy habits are still important to reduce your risk as much as possible.
Having a carotid artery procedure may help prevent a stroke in the long term. But it's not clear that it will reduce stroke risk much more than medicines and healthy habits alone.
In the short term, carotid artery procedures can increase the risk of stroke and death. You'll need to decide if the possible long-term benefit is worth the short-term risk.
You don't need to make this decision right away. You can take your time to think about your choices and decide what feels right for you.

FAQs

How does carotid artery stenosis raise your risk of stroke?

Carotid artery stenosis is a narrowing of one or both of the carotid arteries, which supply blood to your brain. These arteries can be narrowed and damaged by plaque buildup (atherosclerosis). If this plaque breaks open, it may form a blood clot, which could move to the brain and cause a stroke.

How can you reduce your risk of stroke?

There are two main ways to reduce the risk of stroke:

Take medicines and make healthy lifestyle changes, such as being more active. This is sometimes called medical therapy.
Have a carotid artery procedure such as carotid surgery (endarterectomy) or carotid stenting to remove the plaque or widen the artery.

Having a procedure does not take the place of medicines and a healthy lifestyle. If you decide to have a procedure, it's still important to take your medicines and have healthy habits to reduce your stroke risk as much as possible.

What medicines and healthy habits can reduce the risk of stroke?

Taking medicines and making healthy lifestyle changes are important for anyone who has narrowing in a carotid artery. These steps help control the conditions that increase your risk of stroke.

Medicines that can help reduce the risk of stroke include:

Blood pressure medicines. These help prevent the damage to blood vessels that can cause plaque to build up.
Statins and other medicines to lower cholesterol.

Healthy habits that can help reduce the risk of stroke include:

Not smoking.
Eating heart-healthy foods.
Being active. Your doctor can tell you what amount and type of activity is right for you.
Staying at a healthy weight or losing weight if you need to.

How well do medicines and healthy habits work?

In people with carotid artery stenosis who take medicine and have healthy habits, about 1 out of 100 will have a stroke each year, and about 99 will not.^{footnote 1}

Your stroke risk may be higher based on things like your age and health. Your doctor can help you understand your risk of stroke.

What are carotid artery procedures?

There are two procedures that can help reduce the risk of stroke: carotid endarterectomy and carotid artery stenting. Endarterectomy is more common than stenting.

Carotid endarterectomy (say "kuh-RAW-tid en-dar-tuh-REK-tuh-mee") is surgery to remove plaque buildup from a carotid artery. During this procedure, a surgeon:

Makes a cut in the neck just below the jaw.
Opens the carotid artery and carefully removes the plaque.
Closes the artery and skin incisions with stitches.

Carotid artery stenting is also called carotid angioplasty. During this procedure, a doctor:

Threads a tube through an artery in the groin or arm and passes it up to the carotid artery.
Inflates a tiny balloon to enlarge the narrowed portion of the artery.
Places a small, expandable tube called a stent to keep the artery open.

How well do carotid artery procedures work?

A carotid procedure may lower the risk of stroke from about 2% per year to 1% per year.^{footnote 2, footnote 3} It might take up to 5 years to get this decrease in stroke risk.^{footnote 4}

Overall, endarterectomy and stenting seem to work about equally well to help prevent stroke.^{footnote 5}

It is not clear that a procedure will reduce stroke risk more than medicines and lifestyle changes alone. Studies are being done to compare current medical therapy with endarterectomy and stenting.

What are the risks of carotid artery procedures?

Having a carotid artery procedure may help prevent a stroke in the long term. But in the short term, it increases the risk of stroke and death.

The risk of serious problems is highest shortly after the procedure is done. The risk decreases over time. In the first 30 days after a procedure, the risk of stroke or death may be about 3%. That means there is a 97% chance that these things may not happen.^{footnote 5}

Endarterectomy and stenting have similar rates of risk.^{footnote 5} But endarterectomy is usually safer than stenting for people older than 70. For people in this age group, the risk of stroke or death from stenting is too high.^{footnote 5}

Other risks of carotid endarterectomy include:

Infection.
Breathing problems.
Nerve damage that could cause serious problems, like trouble swallowing.

Other risks of carotid artery stenting include:

Infection.
Bleeding or damage to the blood vessel at the catheter insertion site.

Your chance of having a serious problem depends on things like your age and your overall health. Your doctor can help you understand your risk of problems from a procedure. It is important that your risk is less than 3%. It is also important to find a surgeon and a hospital that are experienced in doing the procedure and have a low rate of serious problems.^{footnote 4}

What tests can help your doctor decide if a procedure is an option for you?

Your doctor may recommend tests such as a carotid angiogram, a carotid ultrasound, or a magnetic resonance angiogram (MRA). These tests can help your doctor:

Measure the amount of narrowing in your carotid arteries. This is usually described as a percentage. For example, if plaque is blocking half of the artery, the doctor may say the artery is 50% narrowed. If plaque is blocking three-quarters of the artery, the doctor may say the artery is 75% narrowed.
Check to see how well blood flows through the area that is narrowed by plaque.
Find out where the narrowing is located. Some of these tests can check the carotid arteries as well as the blood vessels above and below the neck.
Find out what kind of plaque is narrowing the artery. But no test can tell for sure which plaques are likely to cause a blood clot to form and cause a stroke.

Why might your doctor suggest a carotid artery procedure?

A doctor may suggest a procedure if it seems likely that the benefits of a procedure will outweigh the risks. To decide if this is the case, a doctor will check several things, including:

The amount of narrowing in your carotid artery. A procedure may be an option if you have severe narrowing. This may mean narrowing of more than 60% to 70%. A procedure is not an option if you have narrowing of less than 50%.
The location of the narrowing in the artery.
Your health. A procedure may be an option if you do not have other serious health problems. Having a serious health problem increases your risk of problems from a procedure.
Your age and life expectancy. A procedure does not reduce your risk of stroke right away. You need to be likely to live for at least 5 more years to get a reduction in stroke risk.

A doctor may give you the option of having a procedure, but this is not a clear-cut decision. It is also not one you have to make in a hurry. You can take time to weigh your choices and decide what feels right for you. How you feel about the risks and benefits is just as important as the medical facts.

Compare your options

Compare


What is usually involved?
What are the benefits?
What are the risks and side effects?

Have a procedure Have a procedure

You will likely stay 1 or 2 nights in the hospital.
You can go back to your daily activities within a week or two, if they are not too strenuous.
You will still need to take medicines and have a healthy lifestyle.

A carotid procedure may reduce the long-term risk of stroke from 2% per year to 1% per year.^{footnote 2, footnote 3}
A procedure is most likely to benefit people who have 60% to 70% or more narrowing of the carotid arteries.^{footnote 4}

There is about a 3% chance that the procedure itself might cause a stroke or death. The risk is highest in the first 30 days after the procedure is done.^{footnote 5}
You may still have a stroke in spite of the procedure. Your artery might become narrow again.
These procedures also have other risks, including bleeding, infection, and nerve damage.

Don't have a procedure Don't have a procedure

You take medicines and have a healthy lifestyle to reduce your risk of stroke.

Medicine and lifestyle changes can lower your risk of stroke.
You avoid the risks of a procedure.

You may still have a stroke.
Medicines and lifestyle changes alone may not lower your long-term risk of stroke quite as much as a procedure would.

Personal stories about carotid artery procedures

These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.

It worries me that one of my carotid arteries is almost 90% narrowed. I don't have any serious health problems, so my doctor said that I am healthy enough to have a procedure. I'm faithful about taking my medicines and I'm active, but I want to get my stroke risk as low as I can. And a procedure could lower my risk a bit more over time. I know a procedure has risks too, but think I want to have one.

David, age 76

I have about 80% narrowing in one of my arteries. My doctor says I could have a procedure, but why would I choose a treatment that would make me more likely to have a stroke in the short term? That doesn't make sense to me. I'll stick with staying healthy by taking my medicines and exercising.

Charlene, age 68

I really worry about having a stroke. I know the procedure might cause a stroke, but I figure I have a better chance of avoiding problems if I have the procedure while I'm still fairly young and healthy. I'm willing to take a risk now to reduce my chance of stroke later in life.

Roberto, age 67

My carotid arteries are about 75% narrowed, but otherwise I'm in pretty good health. I take my medicines the way I'm supposed to, and they help lower my risk of stroke. My doctor says this isn't an urgent decision, so for now I'm not going to have a procedure. And I'll think carefully about whether it's something I might want to have later.

Golda, age 71

What matters most to you?

Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.

Reasons to have a carotid procedure

Reasons not to have a carotid procedure

I'm very worried about my long-term risk of having a stroke and want to do everything I can to prevent it.

I'm not very worried about having a stroke.

More important

Equally important

More important

I want to lower my long-term risk of stroke as much as I can.

I want to avoid the serious risks of a procedure.

More important

Equally important

More important

I take medicines and have healthy habits, but I want to reduce my stroke risk even more.

I'd rather do everything I can to reduce my stroke risk with medicines and healthy habits alone.

More important

Equally important

More important

My other important reasons:

More important

Equally important

More important

Where are you leaning now?

Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.

Having a carotid artery procedure

NOT having a carotid artery procedure

Leaning toward

Undecided

Leaning toward

Your Summary

Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision.

Your decision

Next steps

Which way you're leaning

How sure you are

Your comments

Your knowledge of the facts

Key concepts that you understood

Key concepts that may need review

Getting ready to act

Patient choices

What matters to you

Print Summary

Credits and References

Credits

Author	Healthwise Staff
Primary Medical Reviewer	E. Gregory Thompson MD - Internal Medicine
Primary Medical Reviewer	Adam Husney MD - Family Medicine
Primary Medical Reviewer	Martin J. Gabica MD - Family Medicine
Primary Medical Reviewer	Robert A. Kloner MD, PhD - Cardiology
Primary Medical Reviewer	Caroline S. Rhoads MD - Internal Medicine

References

Citations

Raman G, et al. (2013). Management strategies for asymptomatic carotid stenosis: A systematic review and meta-analysis. Annals of Internal Medicine, 158(9): 676–685. DOI: 10.7326/0003-4819-158-9-201305070-00007. Accessed February 23, 2015.
Halliday A, et al. (2004). Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: Randomized controlled trial. Lancet, 363(9420): 1491–1502. DOI: 10.1016/S0140-6736(04)16146-1. Accessed June 18, 2015.
Halliday A, et al. (2010). 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): A multicentre randomised trial. Lancet, 376(9746): 1074–1084. DOI: http://dx.doi.org/10.1016/S0140-6736(10)61197-X. Accessed June 17, 2015.
Meschia JF, et al. (2014). Guidelines for the primary prevention of stroke: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, published online October 28, 2014. DOI: 10.1161/STR.0000000000000046. Accessed October 29, 2014.
Brott TG, et al. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. New England Journal of Medicine, 363(1): 11–23.

Stroke Prevention: Should I Have a Carotid Artery Procedure?

Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision.

Get the facts
Compare your options
What matters most to you?
Where are you leaning now?
What else do you need to make your decision?

1. Get the Facts

Your options

Have a carotid artery procedure along with taking medicines and making healthy lifestyle changes to help prevent a stroke.
Don't have a procedure. Reduce stroke risk by taking medicines and having healthy habits.

Key points to remember

Narrowing (stenosis) in a carotid artery increases your risk of stroke, so it's important to do what you can to lower your risk.
A carotid artery procedure may be an option if you have narrowing of 60% to 70% or more. A procedure is not an option if you have narrowing of less than 50%. You are less likely to get a carotid artery procedure if you do not have symptoms, regardless of the amount of narrowing.
Taking medicines and having healthy habits can help lower your risk of stroke. If you decide to have a procedure, medicines and healthy habits are still important to reduce your risk as much as possible.
Having a carotid artery procedure may help prevent a stroke in the long term. But it's not clear that it will reduce stroke risk much more than medicines and healthy habits alone.
In the short term, carotid artery procedures can increase the risk of stroke and death. You'll need to decide if the possible long-term benefit is worth the short-term risk.
You don't need to make this decision right away. You can take your time to think about your choices and decide what feels right for you.

FAQs

How does carotid artery stenosis raise your risk of stroke?

How can you reduce your risk of stroke?

There are two main ways to reduce the risk of stroke:

Take medicines and make healthy lifestyle changes, such as being more active. This is sometimes called medical therapy.
Have a carotid artery procedure such as carotid surgery (endarterectomy) or carotid stenting to remove the plaque or widen the artery.

What medicines and healthy habits can reduce the risk of stroke?

Taking medicines and making healthy lifestyle changes are important for anyone who has narrowing in a carotid artery. These steps help control the conditions that increase your risk of stroke.

Medicines that can help reduce the risk of stroke include:

Blood pressure medicines. These help prevent the damage to blood vessels that can cause plaque to build up.
Statins and other medicines to lower cholesterol.

Healthy habits that can help reduce the risk of stroke include:

Not smoking.
Eating heart-healthy foods.
Being active. Your doctor can tell you what amount and type of activity is right for you.
Staying at a healthy weight or losing weight if you need to.

How well do medicines and healthy habits work?

In people with carotid artery stenosis who take medicine and have healthy habits, about 1 out of 100 will have a stroke each year, and about 99 will not.¹

Your stroke risk may be higher based on things like your age and health. Your doctor can help you understand your risk of stroke.

What are carotid artery procedures?

There are two procedures that can help reduce the risk of stroke: carotid endarterectomy and carotid artery stenting. Endarterectomy is more common than stenting.

Carotid endarterectomy (say "kuh-RAW-tid en-dar-tuh-REK-tuh-mee") is surgery to remove plaque buildup from a carotid artery. During this procedure, a surgeon:

Makes a cut in the neck just below the jaw.
Opens the carotid artery and carefully removes the plaque.
Closes the artery and skin incisions with stitches.

Carotid artery stenting is also called carotid angioplasty. During this procedure, a doctor:

Threads a tube through an artery in the groin or arm and passes it up to the carotid artery.
Inflates a tiny balloon to enlarge the narrowed portion of the artery.
Places a small, expandable tube called a stent to keep the artery open.

How well do carotid artery procedures work?

A carotid procedure may lower the risk of stroke from about 2% per year to 1% per year.^{2, 3} It might take up to 5 years to get this decrease in stroke risk.⁴

Overall, endarterectomy and stenting seem to work about equally well to help prevent stroke.⁵

It is not clear that a procedure will reduce stroke risk more than medicines and lifestyle changes alone. Studies are being done to compare current medical therapy with endarterectomy and stenting.

What are the risks of carotid artery procedures?

Having a carotid artery procedure may help prevent a stroke in the long term. But in the short term, it increases the risk of stroke and death.

Endarterectomy and stenting have similar rates of risk.⁵ But endarterectomy is usually safer than stenting for people older than 70. For people in this age group, the risk of stroke or death from stenting is too high.⁵

Other risks of carotid endarterectomy include:

Infection.
Breathing problems.
Nerve damage that could cause serious problems, like trouble swallowing.

Other risks of carotid artery stenting include:

Infection.
Bleeding or damage to the blood vessel at the catheter insertion site.

What tests can help your doctor decide if a procedure is an option for you?

Your doctor may recommend tests such as a carotid angiogram, a carotid ultrasound, or a magnetic resonance angiogram (MRA). These tests can help your doctor:

Measure the amount of narrowing in your carotid arteries. This is usually described as a percentage. For example, if plaque is blocking half of the artery, the doctor may say the artery is 50% narrowed. If plaque is blocking three-quarters of the artery, the doctor may say the artery is 75% narrowed.
Check to see how well blood flows through the area that is narrowed by plaque.
Find out where the narrowing is located. Some of these tests can check the carotid arteries as well as the blood vessels above and below the neck.
Find out what kind of plaque is narrowing the artery. But no test can tell for sure which plaques are likely to cause a blood clot to form and cause a stroke.

Why might your doctor suggest a carotid artery procedure?

A doctor may suggest a procedure if it seems likely that the benefits of a procedure will outweigh the risks. To decide if this is the case, a doctor will check several things, including:

The amount of narrowing in your carotid artery. A procedure may be an option if you have severe narrowing. This may mean narrowing of more than 60% to 70%. A procedure is not an option if you have narrowing of less than 50%.
The location of the narrowing in the artery.
Your health. A procedure may be an option if you do not have other serious health problems. Having a serious health problem increases your risk of problems from a procedure.
Your age and life expectancy. A procedure does not reduce your risk of stroke right away. You need to be likely to live for at least 5 more years to get a reduction in stroke risk.

2. Compare your options

	Have a procedure	Don't have a procedure
What is usually involved?	You will likely stay 1 or 2 nights in the hospital. You can go back to your daily activities within a week or two, if they are not too strenuous. You will still need to take medicines and have a healthy lifestyle.	You take medicines and have a healthy lifestyle to reduce your risk of stroke.
What are the benefits?	A carotid procedure may reduce the long-term risk of stroke from 2% per year to 1% per year.^{2, 3} A procedure is most likely to benefit people who have 60% to 70% or more narrowing of the carotid arteries.⁴	Medicine and lifestyle changes can lower your risk of stroke. You avoid the risks of a procedure.
What are the risks and side effects?	There is about a 3% chance that the procedure itself might cause a stroke or death. The risk is highest in the first 30 days after the procedure is done.⁵ You may still have a stroke in spite of the procedure. Your artery might become narrow again. These procedures also have other risks, including bleeding, infection, and nerve damage.	You may still have a stroke. Medicines and lifestyle changes alone may not lower your long-term risk of stroke quite as much as a procedure would.

Personal stories

Personal stories about carotid artery procedures

These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.

"It worries me that one of my carotid arteries is almost 90% narrowed. I don't have any serious health problems, so my doctor said that I am healthy enough to have a procedure. I'm faithful about taking my medicines and I'm active, but I want to get my stroke risk as low as I can. And a procedure could lower my risk a bit more over time. I know a procedure has risks too, but think I want to have one."

— David, age 76

"I have about 80% narrowing in one of my arteries. My doctor says I could have a procedure, but why would I choose a treatment that would make me more likely to have a stroke in the short term? That doesn't make sense to me. I'll stick with staying healthy by taking my medicines and exercising."

— Charlene, age 68

"I really worry about having a stroke. I know the procedure might cause a stroke, but I figure I have a better chance of avoiding problems if I have the procedure while I'm still fairly young and healthy. I'm willing to take a risk now to reduce my chance of stroke later in life."

— Roberto, age 67

"My carotid arteries are about 75% narrowed, but otherwise I'm in pretty good health. I take my medicines the way I'm supposed to, and they help lower my risk of stroke. My doctor says this isn't an urgent decision, so for now I'm not going to have a procedure. And I'll think carefully about whether it's something I might want to have later."

— Golda, age 71

3. What matters most to you?

Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.

Reasons to have a carotid procedure

Reasons not to have a carotid procedure

I'm very worried about my long-term risk of having a stroke and want to do everything I can to prevent it.

I'm not very worried about having a stroke.

More important

Equally important

More important

I want to lower my long-term risk of stroke as much as I can.

I want to avoid the serious risks of a procedure.

More important

Equally important

More important

I take medicines and have healthy habits, but I want to reduce my stroke risk even more.

I'd rather do everything I can to reduce my stroke risk with medicines and healthy habits alone.

More important

Equally important

More important

My other important reasons:

More important

Equally important

More important

4. Where are you leaning now?

Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.

Having a carotid artery procedure

NOT having a carotid artery procedure

Leaning toward

Undecided

Leaning toward

Credits

By	Healthwise Staff
Primary Medical Reviewer	E. Gregory Thompson MD - Internal Medicine
Primary Medical Reviewer	Adam Husney MD - Family Medicine
Primary Medical Reviewer	Martin J. Gabica MD - Family Medicine
Primary Medical Reviewer	Robert A. Kloner MD, PhD - Cardiology
Primary Medical Reviewer	Caroline S. Rhoads MD - Internal Medicine

References

Citations

Raman G, et al. (2013). Management strategies for asymptomatic carotid stenosis: A systematic review and meta-analysis. Annals of Internal Medicine, 158(9): 676–685. DOI: 10.7326/0003-4819-158-9-201305070-00007. Accessed February 23, 2015.
Halliday A, et al. (2004). Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: Randomized controlled trial. Lancet, 363(9420): 1491–1502. DOI: 10.1016/S0140-6736(04)16146-1. Accessed June 18, 2015.
Halliday A, et al. (2010). 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): A multicentre randomised trial. Lancet, 376(9746): 1074–1084. DOI: http://dx.doi.org/10.1016/S0140-6736(10)61197-X. Accessed June 17, 2015.
Meschia JF, et al. (2014). Guidelines for the primary prevention of stroke: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, published online October 28, 2014. DOI: 10.1161/STR.0000000000000046. Accessed October 29, 2014.
Brott TG, et al. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. New England Journal of Medicine, 363(1): 11–23.

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