Reporter: Hello Professor Fu, can you please introduce what is extracranial carotid artery sclerosis occlusion? What is the relationship between it and what we call “stroke” and “mini-stroke”? Fu Weiguo: Extracranial carotid atherosclerosis is also known as carotid atherosclerosis, which is closely related to hyperlipidemia, diabetes and hypertension, mainly manifested as lipid accumulation, fibrous hyperplasia and even calcification on the wall of the carotid artery, especially the internal carotid artery supplying cerebral blood supply, forming sclerotic plaques, which protrude into the arterial lumen and lead to arterial stenosis, affecting cerebral blood supply. More importantly, as Cheng said earlier, under the continuous impact of blood flow, the fragments produced by plaque degeneration fall off and enter the skull with the blood flow, causing small artery embolism, resulting in ischemic necrosis of brain tissue in the blood supply area, which manifests the symptoms of cerebral infarction. I also want to correct Cheng’s misunderstanding that the fragments of carotid plaque will not flow to the heart. In addition, if the plaque is mainly composed of lipid and fiber, it is called unstable plaque, and the surface fragments are easy to be dislodged, so it is easy to have cerebral infarction, and sometimes the plaque also has secondary bleeding and ulceration, so there are more fragments and easier to be dislodged, so the risk is higher. 80% of what we call “strokes” are ischemic strokes, or “cerebral infarction” in medical terms. “Small strokes” are also known as transient ischemic attacks (TIA). They are all closely related to carotid artery sclerosis and occlusive disease. Since 1995, the Department of Vascular Surgery of Zhongshan Hospital has been the first in China to conduct carotid ultrasound screening for patients with cerebral ischemic stroke or transient cerebral ischemia, and found that 56.6% had significant atherosclerotic plaques, of which the incidence of severe stenosis was as high as 12.5% respectively, confirming the close relationship between patients with cerebral ischemia and extracranial carotid artery lesions in China. Reporter: So is it really possible to prevent cerebral infarction by opening? What about the often mentioned “dissection” and “stenting”? Fu Weiguo: Since many cerebral infarctions are caused by the stenosis or occlusion of carotid arteries after atherosclerosis, is it possible to prevent cerebral infarction by applying surgical methods to remove the plaque and lift the stenosis? In response to this situation, carotid endarterectomy (commonly known as “dissection”) was first tried abroad in 1954 to treat extracranial carotid atherosclerosis occlusive disease and prevent cerebral infarction. This procedure simply involves cutting open the narrowed carotid artery under direct vision, stripping away the sclerotic plaque, and then suturing the carotid artery together. It is important in the prevention and treatment of TIA and cerebral infarction because it not only restores the diameter of the stenosed carotid artery and increases cerebral blood flow, but also eliminates the source of microemboli. After years of clinical trials and demonstrations, it has become the standard procedure for the treatment of extracranial carotid artery sclerosis occlusive disease and has been promoted on a large scale in western countries. The status of anatomy and surgery in the 20th century has determined most surgeons to revere surgical treatment, which has led to the full development of surgical methods. However, the rate of surgical complications was high in high-risk patients, such as advanced age, severe cardiopulmonary disease, renal insufficiency, contralateral carotid occlusion, and history of previous carotid surgery. So, while surgery was developing, surgeons and interventional radiologists searched for a less invasive, simpler and less complicated procedure – carotid stenting (commonly known as “stenting”). A stent is a tubular mesh prosthesis made of nickel-titanium memory alloy, which is delivered to the carotid artery lesion through a catheter under X-ray fluoroscopy in a minimally invasive way, allowing the stent to hold the plaque in place and prevent dislodgment, and using the elasticity of the stent to hold the stenosis open. In recent years, stenting has been increasingly used in the treatment of extracranial carotid artery sclerosis occlusive disease, especially for those patients at high risk. Since 1992, our department has been the first in China to perform carotid endarterectomy in patients with severe stenosis of extracranial carotid sclerosis occlusion, and more than 150 cases have been performed. Since then, carotid artery stenting has been carried out, and there have been 91 cases so far, with positive results and good prevention of cerebral infarction. Reporter: What symptoms need to come to the doctor? Fu Weiguo: The early manifestation of cerebral infarction is TIA, and 60% of TIA is caused by simple stenosis of the internal carotid artery, and the preferred site is often at the beginning of the bifurcation of the common carotid artery. The manifestation of cerebral ischemia occurs when the stenosis of the internal carotid artery exceeds 70% of its diameter. Since the main branch of the internal carotid artery is the middle cerebral artery, its most characteristic manifestations are contralateral upper and lower extremity weakness, ipsilateral transient blackout, and transient speech impairment. The attacks are usually only a few minutes long and mostly resolve within an hour, with the longest duration not exceeding 24 hours. If the above symptoms appear, you should go to the hospital promptly. Foreign countries recommend that patients with the first attack of TIA should be hospitalized within 24 to 48 hours to facilitate early examination and treatment to prevent the development of cerebral infarction. In China, carotid Doppler ultrasound, transcranial Doppler ultrasound, hematology, electrocardiography and echocardiography, CT or MRI are also advocated in order to facilitate the determination of the cause and subsequent preventive treatment measures. Of these, Doppler ultrasound is most commonly used to screen those with carotid or vertebral artery lesions. Screening can be followed by imaging tests such as CT, MRI or angiography to clarify the length and degree of stenosis of the lesion and provide a basis for surgery or endoluminal treatment. Reporter: Which patients should undergo surgery or endoluminal treatment? Weiguo Fu: Before the 1980s, scholars believed that symptomatic internal carotid artery stenosis with a stenosis of more than 75% should be treated with carotid endarterectomy. Studies in the last decade have shown that, in addition to the indications for appeal, carotid endarterectomy should be actively performed in patients with high-risk factors for cerebral infarction, with stenosis >50% in symptomatic patients and >60% in asymptomatic patients. The indications for stentoplasty have also converged after a period of debate. Simply put, this means: patients with symptomatic stenosis with >70% diameter stenosis but who are not candidates for surgery or have risk factors for surgery. In the half century of development of carotid artery stenosis surgery, it has gone through the stages of routine surgery, simple balloon dilation, and stenting. The surgical approach has been simplified, the time has been shortened, the risk of surgery has been reduced, and the indications for surgery have been expanded. The update of the surgical approach to carotid stenosis is also in line with the general direction that vascular surgery is moving from the traditional approach to endoluminal treatment and from macroinvasive to minimally invasive. We recommend that middle-aged and elderly people, if they show signs of TIA or cerebral infarction, go to a regular hospital in time to get a clear diagnosis and choose the appropriate treatment under the guidance of a doctor. Reporter: Do you have any suggestions for the prevention of carotid artery sclerosis occlusive disease? Fu Weiguo: Vascular disease is a disease of the elderly, usually occurring in the fifties and sixties. Although it is said that old age, sickness and death are the objective laws of nature and cannot be resisted, we can still slow down aging and live a healthy life through our own efforts. From a medical point of view, we recommend treating hyperlipidemia and hypercholesterolemia. Limit the amount of cholesterol in food; reduce saturated fatty acids and increase polyene fatty acids; increase mixed carbohydrates in food appropriately; reduce total calories, maintain ideal body weight and engage in regular physical activity. Patients with diabetes should make efforts to control blood glucose. Treatment of hypertension should aim at a systolic blood pressure below 140 mmHg and a diastolic blood pressure below 90 mmHg. For patients with combined diabetes, blood pressure is recommended.