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Minimally-Invasive Procedures Compare Favorably to Major Surgery

For caring, highly skilled doctors, there is nothing more exciting than being able to provide patients with safe, minimally-invasive options to major surgery. At First Coast Cardiovascular Institute (FCCI), that excitement is growing because of the results of the new CREST study which supports findings of the established SAPPHIRE study in treating dangerous carotid artery plaque buildup that causes arteries to narrow.

What’s new is evidence that carotid artery stenting, a procedure performed hundreds of times by the cardiologists at FCCI, may be as effective if not more effective as the more invasive carotid endarterectomy procedure in the high surgical risk patients or standard risk patients.

Some of the high risk patients include patients with COPD, contraindications to anesthesia, congestive heart failure, previous carotid surgery or neck surgery, history of angina or recent stent placement, recent heart attack, blockage can not be reached by traditional surgery, renal disease or failure etc.

“Carotid artery stenting is a procedure similar to one commonly used to open narrowed arteries in the heart,” says Dr. Majdi Ashchi, senior founding physician and medical director of FCCI. “We are able to use angioplasty combined with stent placement with use of some type of embolic protections device as an alternative to traditional surgery for preventing transient ischemic attacks (TIA), strokes and even death.”

The procedure, which uses a catheter, is threaded through an artery in the groin and passed up to the carotid arteries. A tiny balloon is used to enlarge the narrowed portion of the artery, and a wire mesh stent is used to keep the artery open.

Dr. Ashchi and his colleagues at FCCI (Drs. Khatib, Ali and Al-Saghir) have been closely following studies that compare the success of carotid stenting procedure to the traditional carotid endarterectomy or CEA surgery. “The carotid stenting procedure has evolved and improved over the past 20 years, to the point that we can safely say its results are equivalent, if not better, for certain patients,” he notes.

“As cardiologists who care about minimizing complications and discomfort to our patients in all circumstances, it’s very important for us to be able to offer minimally-invasive options,” Dr. Ashchi continues. “Many patients with carotid artery blockage now have another option to the traditional surgery. Traditional surgery requires general anesthesia, an incision in the neck and typically a two to three day hospital stay. The traditional method always involves a risk of complications, even when done by the most skilled surgeons.”

Detecting Blockage

Since carotid blockage may cause no symptoms at all until it is too late, patients should always ask to have their doctor listen to their carotid artery as part of their routine physical exam. Doctors can detect some abnormalities simply by listening to blood flow with a stethoscope.

This is a potentially life-saving step, says Dr. Ashchi. “Patients may not know they are walking around with a ‘time bomb’ that could lead to death. Early detection can allow us to address the condition before it causes TIA, stroke or even death”.

If there is an indication that the blood flow does not sound completely normal or there are any other symptoms, further testing can be conducted, in the form of carotid ultrasound, magnetic resonance angiogram (MRA), computed tomography (CTA) or even angiography.

Some of the imaging diagnostic tests can also detect disease in the blood vessels above and below the neck. If blockage exists high in the neck, in the brain or below the clavicle, then traditional CEA may not be the best approach to revascularization or cleaning of these arteries but stenting would be a better choice.

No test can predict accurately which plaques are likely to cause a blood clot to form or a plaque or blockage to rupture and cause a TIA or stroke. But experts believe that irregular, jagged or unstable (ulcerated) plaques are more likely than smooth plaques to cause TIA or stroke. The thickness of carotid blockage or “plaque” does correlate with increased risk of heart attacks.

Discussing Options with Your Doctor

Patients who have been told they need surgery for carotid blockage should talk with their doctor about whether carotid stenting is an option for their specific case. “Not everyone is a candidate, but it’s important to have that discussion,” says Dr. Ashchi. “Certain risk factors may influence the choice of one procedure over the other.”

Choosing a Doctor for a Stenting Procedure

When a patient is a candidate for the carotid stenting procedure, there are certain criteria to consider, says Dr. Ashchi. “The technology has evolved a great deal, and patients will want to ask how many carotid stenting procedures a physician has performed. Look for experienced physicians who have completed at least 50 to 100 procedures with low complication rates. Be sure to select a doctor who has experience using stents and embolic protection devices of all types. These devices are used to prevent debris or clots from traveling to the brain during the procedure and causing TIA or stroke. The rate of complications decrease with experienced physicians and hospitals, like Memorial Hospital Jacksonville, where a large volume of these types of procedures have been performed.

Dr. Ashchi and the team of cardiologists at FCCI have been involved in hundreds of carotid angioplasty and stent procedures. Over the years, Dr. Ashchi and his partners have served as principal investigator in several national carotid angioplasty stenting and registry trials as the procedure has evolved.

First Coast Cardiovascular Institute has performed the highest number of carotid stenting procedures of any Jacksonville area cardiology group and is ranked among the top in the nation. “Working as a team, we provide an extra level of expertise, discussing complicated cases with one another to achieve the best possible result for each patient,” says Dr. Ashchi. “Along with our commitment to excellence comes a low incidence of complications—we have a rate of complications that is less than the national average.”

The FCCI team has experience using a variety of devices, including the Mo.Ma Ultra Cerebral Protection Device. Dr. Ashchi was the first doctor in the Southeastern U.S. to use the device following its release by the FDA just months ago. The Mo.Ma device makes angioplasty safer by keeping blood clots or debris from traveling to the brain and potentially causing a stroke.

Follow-up care is an essential component to consider when choosing a cardiologist, says Dr. Ashchi. “We have accredited vascular technologists, along with an accredited vascular laboratory in our offices, so we can monitor patients for re-stenosis (reoccurrence of blockage) and progression of disease. There has to be a protocol to follow these patients.”

Expertise Expands into Clay County

Dr. Youssef Al-Saghir joined FCCI after completing cardiovascular training at the University of Utah. He is the first board-certified cardiologist in Clay County to offer carotid stenting at Orange Park Medical Center. Dr. Al-Saghir is board certified in Cardiovascular Disease, Interventional Cardiology and Endovascular Medicine. He is a member of both the American College of Physicians and American College of Cardiology. He has also been the author/co-author of several articles published in peer-reviewed journals.

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