The carotid arteries are the two large blood vessels you can feel the pulse of in your neck that bring oxygenated blood to the brain. Narrowing or blocking of these arteries can cause life threatening consequences, including a major stroke. Often diagnosable by a doctor during the exam by listening for a bruit over the arteries themselves, it is just as often found after a major event such as a transient ischemic attack or a full blown stroke. There’s still not universal agreement on a uniform treatment for carotid stenosis, and confusion has been added by the U.S. Preventative Services Task Force which recommends against routine screening for carotid stenosis in the general population. Nonetheless, it is an important consequence of vascular disease and always has to be accounted for in underwriting.
Stroke is the third leading cause of death in the United States and the leading cause of disability. A narrowing of the carotid artery (or arteries) may be a precursor to strokes or transient ischemic attacks (TIA) because of small emboli (clots) that can pass unimpeded to the brain or from significant narrowing that limits proper blood flow. 10-15 percent of strokes are associated with carotid artery stenosis, and up to eight percent of adults are estimated to have some degree of carotid narrowing.
Usually carotid artery stenosis isn’t an isolated finding. If there is stenosis present, there is likely narrowing of other blood vessels in the body as well. Most cases are from a plaque buildup (atheroma) at the origin of the carotid artery. Sometimes it is caused as a complication from another procedure being done in the same anatomical vicinity. Stenosis is somewhat more common in women than men and is often a disease of aging.
A doctor can diagnose carotid artery stenosis often by listening above the artery with a stethoscope. A loud rumbling noise (called a bruit) shows rough and somewhat impeded blood flow. Stenosis can occur without a bruit, and unfortunately the result of the narrowing or closure (like the TIA or stroke mentioned) often leads to the diagnosis after the fact. Generally the initial test done is an ultrasound, which can diagnose a blockage or the presence of an obstruction. MRI then gives a better quantitative measure of how extensive the blockage is and where exactly the lesion is compromising blood flow.
With this, despite several major trials on the proper treatment of carotid stenosis including the Endarterectomy for Asymptomatic Carotid Atherosclerosis Study, the Asymptomatic Carotid Surgery Trial, and the Veterans Affairs Cooperative Study, there’s no uniform agreed upon path for treatment. Obviously, the end goal is the prevention of future strokes and other complications of atherosclerosis. Medications that reduce the tendency to form clots (such as aspirin and ticlopidine) and blood thinners are used on both an acute and chronic basis. Control of high blood pressure is instituted and carefully monitored, diseases like diabetes are more firmly controlled, and above all smoking cessation is recommended.
When carotid stenosis or closure of the arteries enters the 60-70 percent range, surgical procedures come to the forefront. A carotid endarterectomy is a procedure where the carotid artery is opened and surgical removal of plaque is accomplished. A newer alternative approach is carotid artery stenting where, as in similar procedures done in the heart, a stent is put in to prop and keep the artery open. So far when feasible, endarterectomy is the procedure more often used since stenting carries a higher short term stroke and death risk even if less invasive.
Underwriters look at age of diagnosis, time since the procedure was successful, severity of disease (and how prevalent it is in other arteries besides the carotids), and other contributory diseases (such as high blood pressure, diabetes, etc.) and how well they are being controlled. There generally has to be a minimum of 6 months of recovery after a procedure, and younger ages are treated more severely than if it occurs further into the process of aging. Presence of diabetes and hypertension adds to the rating as an ongoing risk factor for recurrent stenosis or stroke. Continued smokers are routinely declined.
