Carotid Artery Stenting

The Boynton Times

Local Surgeon Implants New Minimally Invasive Carotid Stent Device and Saves One Man's Life

Boynton Beach, FL. By the time Joseph Camiso was 73, he already had a six-vessel coronary bypass surgery. He had also undergone carotid artery surgery, called endartectomy, which is performed for patients whose carotid arteries have narrowed because of cholesterol buildup. The threat of stroke caused by clogged carotid arteries is not uncommon.

The endartectomy created a large scar on the left side of his neck, but more concerning was that the nerve supplying the left vocal cord was damaged leaving that side of his throat paralyzed.

“I sounded like a character from ‘The Godfather,’” said Mr. Comiso.

Unfortunately, his carotid artery on the right side was also dangerously narrowed and needed to be opened to prevent a stroke. Mr. Comiso and his wife, Marie, then visited an ear, nose, and throat specialist to discuss having an endartectomy for the right carotid artery, but the specialist told them that it was too dangerous. If the nerve supplying the right vocal cord was damaged from the incision, he would be unable to speak or breathe and an emergency tracheotomy tube would be needed.

“My doctor thought that I was too high risk to have another surgery because of the vocal cord paralysis,” he said.

Traditional carotid artery surgery can pose complications in healthier patients as well, including strokes and heart attacks. For Mr. Comiso, the traditional surgery would have been dangerous and likely impossible.

The Comisos then visited their neurologist who referred them to Dr. William Julien, a Board Certified Interventional Radiologist who practices full time endovascular surgery in Margate, FL.

“We were buying against time,” said Mrs. Comiso.

Dr. Julien enrolled Mr. Comiso into an FDA-approved carotid stent research trial for patients who are considered high risk for traditional carotid endartectomy surgery. The procedure offers a life-saving alternative for these patients and was sponsored by Boston Scientific Corporation. Only 780 people were enrolled, and Mr. Comiso was one of them. Since his left vocal cord was already paralyzed, his physicians determined that traditional surgery was too high a risk. Losing control of both sides of his vocal cords could have led to an emergency tracheotomy.

Carotid stenting is a minimally invasive procedure performed by inserting a catheter in the femoral artery passing it through the blood system and up into the carotid artery using X-ray guidance to navigate through the bloodstream. A novel filter device which looks like a tiny butterfly net is first inserted and positioned in the carotid artery downstream from the narrowing. The filter captures any particles that are inadvertently dislodged during the procedure while maintaing blood flow to the brain. An angioplasty balloon then expands the carotid narrowing followed by placement a tubular metal mesh called a stent. This stent acts as a scaffolding to hold the artery open. The final step is removing the filter along with any debris that was trapped during the procedure.

"I feel great. My voice is much better," said Mr. Comiso. "Dr. Julien was wonderful. This procedure not only saved my life but gave me my voice back. I am happy to share my story with others because it may save more lives. Patients and doctors need to know that this is available."

"Mr. Comiso was a delight to work with, and it was gratifying to use this new technology for his serious situation. Since the carotid stent procedure avoids any neck incisions, there is zero risk of vocal cord paralysis," said Dr. Julien. "My practice philosophy is to offer each patient the latest and best technologies, procedures, and medications currently available. Clearly, we were able to accomplish that here."

Dr. Julien emphasizes the importance of patient education and clear explanations on the details of a diagnosis, including short and long-term treatment plans, alternative treatment, and precisely what each patient should expect to experience. His practice has been highlighted as a model for the next generation of Interventional Radiology Practices.

The Guidant Corporation received the first FDA approval for a carotid stent platform on August 31, 2004 and Dr. Julien was the first South Florida physician to implant the newly approved device. The Boston Scientific device that Mr. Comiso had implanted as part of the research trial is expected to be FDA approved third quarter 2005. Dr. Julien's practice will serve as one of a few physician training sites. One of the innovative techniques used during the training will be the use of a sophisticated simulator that allows surgeons to practice on a dummy rather than a real patient.

“We think simulator training will become an important tool in training surgeons performing technically demanding and risky procedures such as carotid stenting,” said Dr. Julien.

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