Hello, My husband is almost 2 years post IMRT for tonsil cancer. Does anyone know if carotid stenosis is a known late complication? He may have had a TIA or "mini stroke". The ER MD wants him to have a full workup, but his primary MD isn't too worried. I am worried!

This is a late complication of all head and neck radiation. My carotids have gone from clear at the beginning, to about 50% occluded now at 10 years out. The issue is not the radiation induced scar tissue occlusion which can make me light headed when I get up from laying down. It IS a problem if he has other risk factors such as high blood lipids, plaques, or calculus in the arteries. These show up on scans differently than scar tissues and certainly different on doppler ultrasounds, so telling this all apart isn't rocket science. Scar tissue is not going to break off and cause any kind of transient ischemic attack or stroke. It is there for the duration. I have had ultrasounds for 6 years in a row and also annual MRI's. No plaques. This issue of not enough blood on occasions to the brain is there, but is this a reason to panic? My cardiologist that has seen lots of H&N patients says no. If it got to the point that it was interfering with my life they could be stented, but he does not recommend that into the foreseeable future. The ER doc you talked to who is not as versed in head and neck radiation patients has this wrong. Unless your husband has had a life of bad diet, lots of fats, and all the things that lead to artery/cardiac illness to begin with, this is not a panic level issue if it is radiation induced. Now you need to evaluate what kind of stenosis exists.

I get light headed when I workout (box) and in some other activities. There is no sudden onset of this except when I get up from a supine position, and I have learned to do that slowly. If he is having any transient vision changes or other things that make you believe he has different risk factors for all this, then he MUST be tested and evaluated fully. I would want someone for whom this was a specialty checking him out, even though dopplers etc. are straightforward to do and read. I would not want an opinion on something that has serious potential to be determined by either an ER room doc (great guys for other things) or a general practice MD. Though from the way you state this some event happened. So a work up is in order to determine cause. While he's at it you might as well see that this evaluation includes a stress test (if he is far enough out of treatment to deal with this) and complete lipid panel, a complete ultrasound of the neck, and if there are other risk factors that show up perhaps even a trans esophageal echo which can see angle to the valves in the heart that external ultrasounds cannot. If he has other risk factors he may need to go on statins and modify other aspects of his life. Carotid stenosis from these lifestyle risk factors is usually not isolated to the carotids.

I was just about to start a thread on this very subject as I sit here waiting on a call back from the cardiovascular doc at my CCC center for a CT angiogram. They think my right carotid is 70% blocked and blame it on radiation.

This started last July. My primary care doc thought he heard a gurgle in my right carotid and ordered an ultrasound in his office. Came back saying rt. 70% blocked. I questioned whether it was scar tissue because the guy running the machine said it was all clear.

Then I had a H&N CT in August at CCC for a different problem, and it said rt carotid all clear and left clogged slightly. So then went to cardiovascular doc at same CCC in December who had another ultrasound run, and this again said rt 70% blocked. He wanted to do an angiogram and an angioplasty since I had had radiation if it really was blocked. I decided to wait until I could investigate more since I had an uncle die in a similar procedure.

I have no symptoms, no light headedness, although I am again getting occassional unexplained BP drop which I haven't seen since before I had cancer. On Provachol and Zetia and have been for years. HDL runs 90-102 LDL 60-80. If I'm out of range it is because HDL is so high.

If I remember correctly, he said that the scarring from the radiation causing the narrowing IS a problem because it could cause the platelets to back up since the passage is so narrow. At what point Brian, does your guy recommend having the surgery and what does he recommend? Love this gift that keeps on giving.

Eileen

I don't have an answer to that question since it has not gotten that bad with me, (remember that I am confident from testing that any lipid issues do not exist I have low LDL and triglycerides, normal to high HDL), and I have not discussed stenting with the doctors because there are some significant downsides to the procedure - and that is using coated or non coated stents, and balloon work is not permanent. Cells backing up in a narrow passage would on the surface seem like a significant problem, but I wonder, given that you have some major percentage of all the blood vessels in your body that are significantly smaller than even a 50% occluded carotid, how important his comment is. After all, don't the platelets go through those smaller vessels? The question becomes how STICKY are those cells, and what is their tendency to clot or form sticky plaques or hard calcifications on artery interiors walls? So to some extent this comes back to other risk factors (blood lipids and existing plaques, high blood pressure and other cardiac issues) as much as percentage of occlusion.

Two people PM'ed me about some of this, so I am going to post it here for general viewing. These are the general risks for strokes. TIA's are a "mini" stroke, and leave no lasting impact BUT THEY ARE WARNING PRECURSORS TO HAVE A FULL BLOWN STROKE.

Risk factors that can be changed, treated or controlled

High blood pressure � High blood pressure is the most important controllable risk factor for stroke. Many people believe the effective treatment of high blood pressure is a key reason for the accelerated decline in the death rates for stroke.
Cigarette smoking � In recent years, studies have shown cigarette smoking to be an important risk factor for stroke. The nicotine and carbon monoxide in cigarette smoke damage the cardiovascular system in many ways. The use of oral contraceptives combined with cigarette smoking greatly increases stroke risk.
Diabetes mellitus � Diabetes is an independent risk factor for stroke. Many people with diabetes also have high blood pressure, high blood cholesterol and are overweight. This increases their risk even more. While diabetes is treatable, the presence of the disease still increases your risk of stroke.
Carotid or other artery disease � The carotid arteries in your neck supply blood to your brain. A carotid artery narrowed by fatty deposits from atherosclerosis (plaque buildups in artery walls) may become blocked by a blood clot. Carotid artery disease is also called carotid artery stenosis. Peripheral artery disease is the narrowing of blood vessels carrying blood to leg and arm muscles. It's caused by fatty buildups of plaque in artery walls. People with peripheral artery disease have a higher risk of carotid artery disease, which raises their risk of stroke.
Atrial fibrillation � This heart rhythm disorder raises the risk for stroke. The heart's upper chambers quiver instead of beating effectively, which can let the blood pool and clot. If a clot breaks off, enters the bloodstream and lodges in an artery leading to the brain, a stroke results.
Other heart disease � People with coronary heart disease or heart failure have a higher risk of stroke than those with hearts that work normally. Dilated cardiomyopathy (an enlarged heart), heart valve disease and some types of congenital heart defects also raise the risk of stroke.
Sickle cell disease (also called sickle cell anemia) � This is a genetic disorder that mainly affects African-American and Hispanic children. "Sickled" red blood cells are less able to carry oxygen to the body's tissues and organs. These cells also tend to stick to blood vessel walls, which can block arteries to the brain and cause a stroke.
High blood cholesterol � People with high blood cholesterol have an increased risk for stroke. Also, it appears that low HDL (�good�) cholesterol is a risk factor for stroke in men, but more data are needed to verify its effect in women.
Poor diet � Diets high in saturated fat, trans fat and cholesterol can raise blood cholesterol levels. Diets high in sodium (salt) can contribute to increased blood pressure. Diets with excess calories can contribute to obesity. Also, a diet containing five or more servings of fruits and vegetables per day may reduce the risk of stroke.
Physical inactivity and obesity � Being inactive, obese or both can increase your risk of high blood pressure, high blood cholesterol, diabetes, heart disease and stroke. So go on a brisk walk, take the stairs, and do whatever you can to make your life more active. Try to get a total of at least 30 minutes of activity on most or all days.

This is from the American Heart Association

What is carotid artery stenosis or carotid artery disease?

Carotid artery stenosis is the narrowing of the carotid arteries. These are the main arteries in the neck that supply blood to the brain. Carotid artery stenosis, also called carotid artery disease, is a major risk factor for ischemic stroke. (This is the most common form of stroke and is usually caused by a blood clot plugging an artery.)

The narrowing is usually caused by plaque in a blood vessel. Plaque forms when cholesterol, fat and other substances build up in the inner lining of an artery. This process is called atherosclerosis.

How is carotid artery stenosis diagnosed?

Carotid artery stenosis may or may not cause symptoms. A doctor may hear an abnormal sound called a bruit (BROO'e) when listening to the artery with a stethoscope. The stenosis can be easily detected with an ultrasound probe placed on the side of the neck near the carotid arteries. This is called carotid ultrasonography.

How is carotid artery stenosis treated?

Depending on the degree of stenosis and the patient's overall condition, carotid artery stenosis can usually be treated with surgery. The procedure is called carotid endarterectomy. It removes the plaque that caused the carotid artery to narrow. Carotid endarterectomy has proven to benefit patients with arteries stenosed (narrowed) by 70 percent or more. For people with arteries narrowed less than 50 percent, anti-clotting medicine is usually prescribed to reduce the risk of ischemic stroke. Examples of these drugs are antiplatelet agents and anticoagulants.

Carotid angioplasty may be another treatment option. It uses balloons and/or stents to open a narrowed artery.

This link takes you to vetted information for those interested in more http://www.americanheart.org/presenter.jhtml;jsessionid=JYVXROYQS1JHQCQFCXQCCZQ?identifier=10000015&q=carotid+artery&x=37&y=9

Thanks for all the information.

The dr said I'm not a candidate for surgical carotid endarterectomy because of the radiation and neck dissection. Don't know why radiation would be a factor since they did a total laryngectomy and left neck dissection on my radiated skin without problems.

I'm now confused on terminology - angiogram vs angioplasty. I know both go in through the groin and clean the carotid artery and thought the angioplasty was when they also stented it. Am I correct? If not what is an angiogram?

You said there were a lot of downsides to a angiogram/plasty and article ten in that last link doesn't seem to recommend them or stents. What are the downsides you know of angioplasty and what are the differences in coated vs uncoated stents?

Thanks in advance,
Eileen

An angiogram is a diagnostic procedure with dye and radiation, the other is a medical procedure to compress the plaques against the artery wall and open things up as in balloon angioplasty.

I am really out of my realm of expertise here, but I will tell you what I have learned from pursuing my own issues only. I want to state clearly that I know lots less about this than I do about cancer and viruses. Balloon agioplasty does indeed smash the build ups against the walls of the artery essentially opening them up, but this is not a permanent situation. You may have to have this done repeatedly. While a very safe procedure that million of which have been done, there is always the risk of braking off a piece of the buildup, and that causing the very thing you were trying to prevent, as that chunk gets pumped down into progressively smaller vessels. Yes you can get put on blood thinners and clot dissolvers while this is all settling in, but shit happens. Ditto when they put in a stent. Stent insertions have had a problem of damaging things and creating clots also, so they started coating them with compounds that would reduce their propensity to do this. Turns out that in long term studies, the coatings had their own issues and did not fully resolve the problem anyway. Having your stent throw a clot is a stroke maker in itself. IN MY OWN PERSONAL SITUATION, I have made the decision to live with things as they are, accepting some of this as part of the new post treatment me. Since it has gotten worse between year 5 and 10, I expect that it might continue to do so, and I will not always have the luxury of this decision and at some point down the road a stent will be the only option for me. I am not there yet, and maybe some MAC truck will take care of me before I get there.

When you consider the "fattening" of America, the foods that the vast majority of American eat (and the volumes of it), the lack of exercise, etc. etc. it is no surprise that the issues of hypertension, and other artery disease, as well as cardiac issues, are at the top of the list of things that kill people. Decades of lifestyle behaviors that put people in these situations cannot easily be undone with a bypass, a stent, or drugs to reduce blood fats, though it is a multi billion dollar marketplace to deal with for the pharma and medical industries.

My reaction to this has been to leave well enough alone unless it is further clogged for all the reasons you suggest. I tried aspirin and it gives me major gas, just like vitamins and other supplements. Seems I developed a reaction to them. I'd be willing to give Plavix a try. Is there a way to test my blood to see if has these clogging platelets?

This operation scares the s... out of me, especially with my trach. What happens if I have to cough up a blob of mucous in the middle of it? I just had a nurse when I had my colonscopy pick up the regular oxygen mask, rather than the trach collar sitting along side it, and try to attach to my mouth. Three times I told this idiot, I am a neck breather, and she still didn't get it. Had I needed that oxygen, I would be dead. Also, sometimes my TEP clogs and I can't talk until I can clear with a brush. How do I then tell these folk what I need if something goes wrong. Do they ever allow a spouse to scrub in so they can be your voice?

You've met me. I'm not overweight, 5'5 and 108. My BP is normal on meds. Been on them since I was 25, inherited BP, not stress or otherwise induced. Cholesteral good. Abdominal CT's do show some calcification but nobody seems concerned. I'll just wait and see what the CT angiogram turns up and make my decision then. Thanks for all the info.

Take care,
Eileen

All blood has platelets. It is the lipids (primarily LDL and HDL) cholesterols and triglycerides that determine if things are going to be sticky or not. All this of course is easily reviewed via conventional fasting blood work to determine risk. BTW baby aspirin (81 mg per day) is a good prophylactic blood thinner.

Eileen
can you tell me about laryngectomys is there a tube that they can instert from the esphogus to the stoma so you can talk normal? I might have to get my voice box removed