Carotid endarterectomy is a surgery done to manage carotid artery disease or carotid artery stenosis. This disorder is caused when fatty, waxy, deposits (plaque) accumulate in the body’s carotid arteries. The carotid arteries are two in number, with each found on either side of the neck. They are responsible for supplying oxygen-rich blood to the neck, face, brain, scalp and head.
The plaque build-up causes the narrowing of one or both carotid arteries and restricts blood flow to the brain, which could lead to a stroke. If a stroke occurs, the brain’s blood supply is stopped. If that continues for a few minutes, brain cells begin to die, and that could result in long-term disability, lasting brain damage, or death.
Carotid artery disease can also lead to a transient ischemic attack (TIA). A TIA shares similar signs and symptoms as a stroke, but they disappear within a day.
The disease can also affect the eyes. When particles from the plaque dislodge from the original site in the carotid artery, they can travel and reach the central retinal artery. Here, they can cause a blockage and result in an ‘eye stroke’. This means that there is a profound and sudden loss of vision.
If a patient suffers from carotid artery disease, they could either be symptomatic or asymptomatic. When the patient is asymptomatic, the condition is usually discovered by a doctor during tests. The risk reduction from the surgery for those experiencing symptoms is more significant when compared to asymptomatic patients.
Carotid endarterectomy is the most common and the usual first course of treatment for carotid artery disease. However, when it’s considered too risky, a substitute surgery known as carotid artery stent placement or carotid artery stenting is done. It is less invasive as an incision isn’t made in the neck. Instead, a stent is put in the carotid artery to expand it, allowing blood to flow steadily. However, carotid artery stenting is considered riskier as the chances of the patient experiencing a stroke during the procedure is higher.
Various factors put people at risk of developing carotid artery disease. They include:
- Pre-existing conditions such as heart disease, hypertension, diabetes or cancer.
- Advanced age – Over the age of 80 years
- Unhealthy diet
- Low or no physical activity
- Previous stroke or TIA history noting the severity and recovery
- Family history of atherosclerosis
This procedure was first performed in 1946 by Joao Cid dos Santos, a Portuguese surgeon. However, the first successful carotid endarterectomy was conducted in 1953 in Texas by Michael DeBakey.
Also Known As
- Carotid Artery Surgery
Before the Procedure
A few weeks before the surgery, the patient is advised to stop smoking as it may increase the chances of developing a chest infection and delay healing, watch their weight (if overweight) by dieting and not engaging in strenuous exercise and stop taking certain medications.
A few days to the procedure, the patient will have a preoperative evaluation done. Here, the surgeon may conduct a cerebral angiogram to get further information on the brain’s anatomy.
On the morning of the procedure, the patient will go through a pre-assessment. At the pre-assessment clinic, they will give their medical history details such as allergies and medication currently being taken. Here, some tests and investigations may be carried out. The patient is required to bring their medication with them.
The patient will lie on the operating table on their back, with their head tilted. The surgeon begins by administering either a local or general anesthetic. When a local anesthetic is used, the patient remains conscious, allowing the surgeon to monitor the brain’s reaction. When a general anesthetic is used, the patient will be unconscious. There’s no evidence that one is better than the other.
The surgeon cleans the area of the neck with an antiseptic to kill any bacteria. If the area is hairy, it will need to be shaved. The patient’s vitals will be monitored all through the procedure. The surgeon then makes an incision on the neck at the site of the blockage, giving access to the carotid artery. S/he then makes another lengthwise incision along the narrowed section of the artery.
Here, the surgeon may decide to insert a temporary, flexible tube, known as a shunt, that diverts blood and ensures adequate blood flow around the area. S/he then proceeds to remove the plaque causing the blockage. Sometimes surgeons use a technique called eversion carotid endarterectomy, where they cut out the artery, turn it inside out to eliminate the plaque, then reattach it.
After removing the shunt, the artery’s opening is closed with stitches using a patch made from a vein or artificial material. The patch widens the artery to prevent it from narrowing again. After the surgeon has ascertained that there is no bleeding, s/he closes the cut in the neck. Sometimes the surgeon may insert a drain to remove any blood that may build up. It is removed the following day.
The procedure takes 1 ½ to 2 hours to complete. If both carotid arteries need to be operated on, one side will be done first and the second will follow after a few weeks.
Risks & Complications
During the time of the surgery, some risks that could arise are bleeding, infection and cranial nerve injury.
The operation may result in temporary postoperative neck discomfort and numbness, which are relieved with over-the-counter pain medications.
Just like any other surgery, there are postoperative risks associated with carotid endarterectomy. The two major ones are:
This may be caused by bleeding in the brain. It may also arise from the formation of a blood clot which moves and blocks an artery in the brain during the early postoperative period.
Although very rare, about 1% of the cases result in death due to stroke or heart attack.
Other possible complications include:
- Reperfusion syndrome - This is a rare complication that occurs in the early stages. The patient experiences a headache and hypertension after surgery.
- Bleeding on the operation site
- Wound infection - This is easily treated using antibiotics.
- Restenosis of the endarterectomy bed - This is when the carotid artery narrows again. Further surgery is required in a small percentage of people.
- Nerve damage - This results in a hoarse voice, weakness or numbness in the face. It disappears after a month.
Aftercare & Recovery
The patient stays in the hospital for a day or two after the procedure. During their hospital stay, their vitals such as blood pressure, breathing and heart rate are closely monitored.
If the patient experiences some discomfort in the neck where the incisions were made, it can be controlled with mild pain relievers. They may also experience numbness in the site, which goes away after a while.
After being discharged, the patient may receive medication to prevent clot formation. Until the incision fully heals, the patient will be required to keep the site clean by gently washing it with mild soap and warm water.
The specialist will advise the patient when it’s safe to resume driving. This is usually after 2-3 weeks. However, if the patient had suffered a stroke of TIA, they’ll be allowed to drive after one month. The patient will be advised to limit strenuous activities, including manual labour and playing sports for a few weeks after surgery. They will be allowed to return to work after a month.
The specialist will advise on the method of removing the stitches on the patient’s neck. The patient will be left with a small scar running from the jaw to the breastbone. It usually fades after three months.
The procedure is not a cure for carotid artery disease as there is a chance that the plaque will build up again. This can be prevented by adopting a healthy lifestyle.