Carotid Endarterectomy

What is a carotid endarterectomy?

A carotid endarterectomy is a surgery to remove plaque buildup from your carotid arteries. It is a treatment for carotid artery disease and can help prevent a stroke. Carotid endarterectomy involves opening the carotid arteries in your neck and removing the inner lining that has become diseased or damaged by plaque.

You have two carotid arteries, one on each side of your neck. They are the major arteries that carry blood from your heart to your brain. A buildup of plaque can narrow or block your carotid arteries. This is called carotid artery disease, and it puts you at risk for stroke.

Carotid endarterectomy is a major surgery with significant risks and potential complications. You may have less invasive treatment options depending on your specific circumstances. You should consider getting a second opinion about all your treatment choices before having a carotid endarterectomy.

Other procedures that may be performed

In addition to a carotid endarterectomy, your doctor may perform one or more diagnostic procedures. These procedures will tell your doctor how much plaque is in your carotid arteries. They include:

• Carotid angiography is a procedure that allows your doctor to take a picture or image (called an angiogram) of your carotid arteries
• Carotid ultrasound is a noninvasive, painless screening test that allows your doctor to examine your carotid arteries and evaluate the flow of blood through them.

Why is a carotid endarterectomy performed?

A carotid endarterectomy is a major surgical procedure that your doctor may recommend to treat carotid artery disease. Carotid artery disease is a buildup of plaque inside your carotid arteries. This narrows your carotid arteries and can eventually block them completely. Carotid artery disease is a serious health condition because it puts you at risk of having a stroke. A stroke is a block in the flow of blood to your brain.

Your doctor may recommend a carotid endarterectomy if other less invasive treatments are not an option. Talk with your doctor about all of your treatment options and consider getting a second opinion.

Your doctor may recommend a carotid endarterectomy if you have carotid artery disease and have any of the following conditions:

• Carotid artery stenosis of 60% or greater. Carotid stenosis is narrowing of your carotid arteries. Your doctor may decide that a carotid endarterectomy is a good preventive treatment for you if your carotid arteries have narrowed by 60% or more. This is true even if you do not have symptoms and have not had a stroke or a TIA.
• Prior stroke
• Prior transient ischemic attacks (TIAs). TIAs are a group of stroke-like symptoms that generally resolve within 24 hours. However, they are warning signs that you are at risk for a severe stroke.

How is a carotid endarterectomy performed?

A vascular surgeon will lead your surgical team and perform your carotid endarterectomy in a hospital. A vascular surgeon is a surgeon who specializes in surgical treatment of diseases of the blood vessels.

A carotid endarterectomy is an open surgical procedure. Open surgery allows your surgeon to directly view and access the surgical area. Your surgeon will make an incision in your neck to expose the diseased part of your carotid artery. Your surgeon will then either clamp your carotid artery closed or place a temporary shunt around your artery.

The next step involves cutting open the diseased part of the artery and removing the inner lining, including the plaque buildup. Your surgeon will then close your artery and unclamp it or remove the shunt. He or she will then close up the incision in your neck.

Open surgery causes a certain amount of trauma to tissues, so it generally takes some time to recover. Your surgeon will determine how long you need to stay in the hospital based on your procedure, age, medical history, and general health.

Types of anesthesia that may be used

Your surgeon will perform a carotid endarterectomy using a nerve block or general anesthesia.

• General anesthesia is a combination of intravenous (IV) medications and gases that put you in a special type of sleep. During general anesthesia, you are unaware of the procedure and will not feel any pain. In some cases, you may also receive a peripheral nerve block infusion in addition to general anesthesia. In a peripheral nerve block infusion, a liquid anesthetic is injected or flows through a tiny tube inserted near your surgical site to control pain during and after surgery.
• A nerve block is also known as regional or local anesthesia. For regional anesthesia, your anesthesiologist or nurse anesthetist will inject an anesthetic medication around certain nerves in the neck to numb the neck. Your doctor may also inject anesthetic in the skin and tissues around the procedure area (local anesthesia).

You will be awake, but kept as comfortable as possible during this procedure. Because you are awake, your surgeon may ask you questions during the procedure. This will help monitor your brain’s response to decreased blood supply while your carotid artery is clamped shut.

What to expect the day of your carotid endarterectomy

The day of your surgery, you can generally expect to:

• Talk with a pre-operative nurse. The nurse will perform an exam and ensure that all needed tests are in order. The nurse can also answer questions and will make sure that you sign the surgical consent. It is important to verify the correct side with the operating staff.
• Remove all clothing and jewelry and dress in a hospital gown. It is a good idea to leave all jewelry and valuables at home or with a family member if possible. The surgical team will respect your privacy and give you blankets for modesty and warmth in the surgical suite.
• Talk with the anesthesiologist or nurse anesthetist about your medical history and the type of anesthesia you will receive.
• A surgical team member will start an IV.
• The anesthesiologist or nurse anesthetist will start your anesthesia. For general anesthesia, your anesthesiologist will place a tube in your lungs to protect and control your breathing. You will not feel or remember this or the surgical procedure as they happen. A catheter may be placed in your bladder to collect urine while you are asleep.
• The surgical team will monitor your vital signs and other critical body functions. This occurs throughout the surgery and your recovery until you are alert, breathing effectively, and your vital signs are stable.

What are the risks and potential complications of a carotid endarterectomy?

Any surgical procedure involves risks and potential complications. Complications may become serious and life threatening in some cases. Complications can develop during the procedure or throughout your recovery.

General risks of surgery

The general risks of surgical procedures include:

• Adverse reaction or problems related to anesthesia, such as an allergic reaction and problems with breathing
• Bleeding, which can lead to shock
• Blood clots, in particular a deep vein thrombosis that develops in the leg or pelvis. A blood clot can travel to your lungs, heart or brain and cause a pulmonary embolism, heart attack, or stroke.
• Infection and septicemia, which is the spread of a local infection to the blood

Potential complications of carotid endarterectomy

Complications of carotid endarterectomy can be serious. You can best reduce the risk of potential complications and help manage complications if any occur by following the treatment plan you and your surgeon design specifically for you. Potential complications include:

• Bleeding in the brain and brain damage
• Death
• Heart attack
• Hyperperfusion syndrome. This can occur when your brain receives normal blood flow after it has had low blood flow to it. A severe headache that improves when you are upright is a classic symptom.
• Low blood pressure, which is usually temporary
• Nerve damage, which is usually temporary. This can make it difficult to swallow and cause numbness in your face.
• Re-stenosis (narrowing) or re-blockage of your carotid artery
• Seizures (rarely)
• Stroke
• Throat swelling making it difficult to breathe

Reducing your risk of complications

You can reduce the risk of certain complications by:

• Ensuring that all members of you care team are aware of any allergies you have
• Following activity, dietary and lifestyle restrictions and recommendations before surgery and during recovery
• Informing your doctor or radiologist if you are nursing or if there is any possibility that you may be pregnant
• Notifying your doctor immediately of any concerns, such as bleeding, fever, increase in pain, or wound redness, swelling or drainage
• Taking your medications exactly as directed

How do I prepare for my carotid endarterectomy?

You are a very important member of your own healthcare team. The steps you take before surgery can improve your outcome after the procedure. You can prepare yourself for a carotid endarterectomy by:

• Answering all questions about your medical history and medications you take. This includes prescribed medications, over-the-counter drugs, herbal treatments, and vitamins. It is a good idea to carry a current list of your medical conditions, previous surgeries, medications, and allergies at all times.
• Getting pre-operative testing as directed. Testing varies depending on your age, health, and specific procedure. Pre-operative testing may include a chest X-ray, electrocardiography (ECG), blood tests, and other tests as needed.
• If you are overweight, talk to your doctor about losing weight before the surgery through a healthy diet and exercise plan.
• If you have high blood pressure, talk to your doctor about how to control it both before and after surgery. Good blood pressure control can help decrease your risk of complications with a carotid endarterectomy.
• Not eating or drinking just prior to surgery as directed. Your doctor may cancel your surgery if you eat or drink too close to the start of the procedure due to the risk of complications. These include choking on stomach contents during deep anesthesia.
• Stop smoking as soon as possible. Even quitting for a just few days can be helpful.
• Taking or stopping medications exactly as directed. For a carotid endarterectomy, this may include not taking aspirin, ibuprofen (Advil, Motrin), and blood thinners.

Questions to ask your doctor

Facing surgery can be stressful. It is common for patients to forget some of their questions during the doctor’s office visit. You may also think of other questions after your appointment. You should contact your doctor with any concerns before surgery.It is also a good idea to bring a list of questions to your pre-operative appointments. Questions can include:

• Why do I need a carotid endarterectomy? Are there any other options for treating my condition?
• How long will the surgery take? When will I be able to go home?
• What restrictions will I have after the surgery? When can I expect to return to work and other activities?
• What kind of assistance will I need at home?
• What medications will I need before and after the surgery?
• How will you manage my pain?
• How should I contact you? When should I see you in follow-up? Ask for numbers to call during and after regular hours.

What can I expect after my carotid endarterectomy?

Knowing what to expect can help make your road to recovery after a carotid endarterectomy as smooth as possible.

How long will it take to recover?

You will need to stay in the hospital for several days after your carotid endarterectomy. After the surgery, you will stay briefly in the recovery room until you are fully alert, breathing effectively, and your vital signs are stable. You may have a drain in your neck to help drain excessive fluids. Your doctor usually removes the drain within a day.

Occasionally, you may be able to go home on the same day if your surgery is very early in the day and you are recovering well. In most cases, a hospital stay of one to two daysis required.

Recovery after surgery is a gradual process. How long it will take for you to recover and return to normal activities depends on the specific surgery, your general health, age, and other factors. Your neck may hurt for several days after surgery. You might also experience some discomfort when swallowing for a few days. Full recovery may take several weeks.

Will I feel pain?

Pain control is an important element to healing and a smooth recovery. There will be discomfort after your surgery. However, you can expect your doctor and care team to manage your pain effectively. This will keep you comfortable so you can get the rest you need. Contact your doctor if you are in pain despite following your pain management plan or if your pain gets worse or changes.

When should I call my doctor?

After a carotid endarterectomy, you should keep your follow-up appointments. You should call your doctor if you have concerns between appointments. Call your doctor right away or seek immediate medical care if you have:

• Change in level of consciousness or alertness, such as passing out, dizziness, unresponsiveness, or confusion
• Change in vision
• Chest pain, chest tightness, chest pressure, or palpitations
• Fever. A low-grade fever (lower than 101 degrees Fahrenheit) is common for a couple of days after surgery and not necessarily a sign of a surgical infection. However, you should follow your doctor’s specific instructions about when to call for a fever.
• Inability to urinate or have a bowel movement
• Leg pain, redness or swelling, especially in the calf, which may indicate a blood clot
• Numbness or weakness on one side of your body or face
• Pain that is not controlled by your pain medication
• Respiratory or breathing problems, such as shortness of breath, difficulty breathing, labored breathing, or wheezing
• Severe headache
• Sudden confusion, problems with speaking or memory, vision problems, dizziness, trouble walking, or loss of balance
• Swelling in your neck
• Uncontrolled or heavy bleeding
• Unexpected drainage, pus, redness or swelling of your incision

How might a carotid endarterectomy affect my everyday life?

A carotid endarterectomy may cure your condition so you can lead an active, normal life. However, it will not prevent carotid artery disease from coming back. You can make changes to your everyday life that may help prevent or delay recurrence of carotid artery disease, such as:

• Eating a heart-healthy diet
• Getting regular exercise
• Maintaining a healthy weight
• Practicing stress management techniques
• Quitting smoking
• Taking blood thinning medications, such as aspirin or clopidogrel (Plavix), as directed by your healthcare provider
• Treating other related conditions, including high blood pressure, high cholesterol, and diabetes