The Patient Was…

The patient was a man in his late fifties who was referred to me for a second opinion regarding surgery for symptomatic narrowing of one of his carotid arteries.

That first sentence is a loaded one because it highlights three separate issues of importance in dealing with the problem the patient presented: surgery versus non-surgical treatment; symptoms versus no symptoms; and carotid arteries versus other arteries. Additionally, it illuminates a crucial question: Who should perform the operation if surgery is indicated?

Let’s start with the carotid arteries. Why are they so important? Arteries, in general, are the blood vessels that carry blood pumped out of the heart around the body. Veins, on the other hand, are the blood vessels that carry blood back to the heart after it has perfused the body tissues. Many arteries are simply named for the organs to which they carry blood, such as renal arteries for the kidneys, and gastric arteries for the stomach. The carotid arteries carry blood to the brain; their name “carotid” comes from a Greek word meaning to “stupefy,” referring to the loss of brain function resulting from blocking their blood flow.

There are two carotid arteries, one on each side of the neck. They are responsible for most of the blood flow to the brain. Obstruction of the blood flow can lead to various forms of brain dysfunction, most commonly stroke. Fortunately, in many cases, a transient form of stroke called a TIA (Transient Ischemic Attack) or ministroke occurs, in which minor and temporary symptoms call attention to inadequate blood flow through the carotid arteries. When recognized, these symptoms should, and in this case did, lead to a prompt evaluation. Once the problem in the carotid artery is diagnosed, a plan of action must be undertaken. 

The patient, a man in his fifties, had experienced two separate episodes of confusion, difficulty speaking, and weakness more on one side of his body than the other. He disregarded the first episode as it passed within a few minutes, and nobody was around to witness it. The second episode, similar to the first, occurred in the presence of his wife, who immediately recognized that something was profoundly wrong, and initiated his medical evaluation. Testing showed a plaque in the wall of one carotid artery, with a roughened surface that lent itself to the formation of tiny clots that then could then travel (embolize) further up the artery into the small blood vessels of the brain tissue itself.

It turns out that many people have plaques in their carotid arteries, a finding commoner as people age. If a plaque is found incidentally, when evaluating  another problem, and a patient has had no symptoms whatsoever, a legitimate case can be made for medical treatment rather than surgery or some other invasive intervention. (Today, invasive procedures other than traditional surgery on the artery are commonplace, but at the time of this patient encounter, it was either open surgery or no intervention other than medical.) But when symptoms occur, especially repeatedly, it is generally conceded that medical therapy alone is not sufficient to prevent a full-blown stroke.

So, the situation was this: blockage and probable recurrent clot formation ln a crucial artery supplying blood to the brain, with symptoms indicating the imminent threat of larger, more permanent damage to brain tissue. The analysis was correct, and the next step was taken appropriately, referral to a surgeon for treatment.

Now, a new question arose: What sort of surgeon should do the curative procedure? General surgeons usually do not have the experience and training to deal with primarily vascular (blood vessel) problems. The proper choice of surgeon is between so-called vascular surgeons, those trained specifically in dealing with blood vessel conditions, and neurosurgeons trained in treating vascular issues involving the brain and nervous system. Depending on their individual experience, either specialist is an acceptable selection.

This patient resided in a suburban area, with an excellent community hospital serving the region. The staff included a vascular surgeon, well trained in the specialty and well regarded in the local medical community. He saw the patient, confirmed the need for an operation, and was prepared to do it. A friend of the patient, who had consulted me in the past, suggested he see me just for a “second opinion” to confirm that the operation was, in fact, necessary.

I arranged a quick appointment for the patient, because delay was not in the best interest of anybody. How tragic would it be if another and more serious event occurred while waiting for a curative procedure! On seeing the patient, I confirmed what had been decided: diagnosis and need for prompt surgery. Before seeing him, however, I had asked him to find out about the local vascular surgeon’s personal experience in doing this type of carotid artery operation. The surgeon indicated that he had performed fifty such procedures with excellent results. The patient was very reassured.

For me, it raised a question. Fifty procedures is quite good experience, but was it the best option available? In the patient’s local community, it was far and away the best. But in my environment, at a university medical center, we had access to excellent surgeons with far greater experience. How much more experience makes a difference? How much more does it take to be better? There is no definitive answer. It’s all qualitative, subjective.

In every procedure, medical or otherwise, there is a learning curve. The more you do it, the better you get at it. You need repeated experience to become expert. When new medical procedures are approved, there are often strict regulations governing who can do what without special supervision. A specific number of procedures under close observation are often mandated, and special restrictions are placed on operators as they “climb the learning curve.”

It so happened that one of the neurosurgeons at my hospital was a specialist in just the kind of carotid artery operation that the patient needed. Patients were referred to him from all over. Coincidentally, I had had occasion to discuss this very type of surgery with him a short while before I saw the patient. The neurosurgeon had done this operation 950 times! There was no complication, no possible untoward event, that he had not encountered and dealt with.

I told the patient about the neurosurgeon’s extraordinary experience with this type of surgery. I did not in any way suggest that his local vascular surgeon would not do a perfect job. The patient did the math: Fifty operations is good experience, but 950 is colossal.

The patient asked for referral to my neurosurgical colleague and was operated on successfully.