Carotid artery surgery
Carotid endarterectomy; CAS surgery; Carotid artery stenosis - surgery; Endarterectomy - carotid artery
Carotid artery surgery is a procedure to treat carotid artery disease.
The carotid artery brings needed blood to your brain and face. You have one of these arteries on each side of your neck. Blood flow in this artery can become partly or totally blocked by fatty material called plaque. This can reduce the blood supply to your brain and cause a transient ischemic attack (TIA) or stroke.
Carotid artery surgery is done to restore proper blood flow to the brain. There are two procedures to treat a carotid artery that has plaque buildup in it. This article focuses on a surgery called carotid endarterectomy. The other method is called angioplasty with stent placement.
A carotid arteriogram is an X-ray study designed to determine if there is narrowing or other abnormality in the carotid artery, a main artery to the brain. This is an angiogram of the left common carotid artery (both front-to-back and side views) showing a severe narrowing (stenosis) of the internal carotid artery just beyond the division of the common carotid artery into the internal and external branches.
This is an angiogram of the right carotid artery showing a severe narrowing (stenosis) of the internal carotid artery just past the carotid fork. There is enlargement of the artery or ulceration in the area after the stenosis in this close-up film. Note the narrowed segment toward the bottom of the picture.
Cholesterol may build-up in the lining of an internal carotid artery.
The build-up of plaque in the internal carotid artery may lead to narrowing and irregularity of the artery's lumen, preventing proper blood flow to the brain. More commonly, as the narrowing worsens, pieces of plaque in the internal carotid artery can break free, travel to the brain and block blood vessels that supply blood to the brain. This leads to stroke, with possible paralysis or other deficits.
The build-up of plaque in the inner layer of the wall of an artery may lead to narrowing and irregularity. Where the narrowing is severe, there is a risk that the vessel can block completely if a thrombus forms in the diseased segment.
There are four carotid arteries, with a pair located on each side of the neck. This includes the right- and left-internal carotid arteries, and the right- and left-external carotid arteries. The carotid arteries deliver oxygen-rich blood from the heart to both the head and brain.
Description
During carotid endarterectomy:
- You receive general anesthesia. You are asleep and pain free. Some hospitals use local anesthesia instead. Only the part of your body being worked on is numbed with medicine so that you do not feel pain. You are also given a medicine to help you relax.
- You lie on your back on an operating table with your head turned to one side. The side your blocked carotid artery is on faces up.
- The surgeon makes a cut (incision) on your neck over your carotid artery. A flexible tube (catheter) is put in the artery. Blood flows through the catheter around the blocked area during surgery.
- Your carotid artery is opened. The surgeon removes the plaque inside the artery.
- After the plaque is removed, the artery is closed with stitches or a patch from one of your veins or synthetic material. Blood now flows through the artery to your brain.
- Your heart activity is monitored closely during surgery.
The surgery takes about 2 hours. After the procedure, your surgeon may do a test to confirm that the artery has been opened.
Why the Procedure Is Performed
This procedure is done if your health care provider has found narrowing or a blockage in your carotid artery. Your provider will have done one or more tests to see how much the carotid artery is blocked.
Surgery to remove the buildup in your carotid artery may be done if the artery is narrowed by more than 70%.
If you have had a stroke or temporary brain injury, your provider will consider whether treating your blocked artery with surgery is safe for you.
Other treatment options your provider will discuss with you are:
- No treatment, other than tests to check your carotid artery every year.
- Medicine and diet to lower your cholesterol.
- Blood-thinning medicines to lower your risk for stroke. Some of these medicines are aspirin, clopidogrel (Plavix), dabigatran (Pradaxa), and warfarin (Coumadin).
Carotid angioplasty and stenting is likely to be used when carotid endarterectomy would not be safe.
Risks
Risks of anesthesia are:
- Allergic reactions to medicines
- Breathing problems
Risks of carotid surgery are:
- Blood clots or bleeding in the brain
- Bleeding requiring re-operation to remove clot
- Brain damage
- Heart attack
- More blockage of the carotid artery over time
- Seizures
- Stroke
- Swelling near your airway (the tube you breathe through)
- Infection
Before the Procedure
Your provider will do a thorough physical exam and order several medical tests.
Tell your provider what medicines you are taking, even medicines, supplements, or herbs you bought without a prescription.
During the 2 weeks before your surgery:
- A few days before the surgery, you may need to stop taking blood-thinning drugs. These include aspirin, ibuprofen (Advil, Motrin), clopidogrel (Plavix), naproxen (Aleve, Naprosyn), and other drugs like these.
- Ask your surgeon which medicines you should still take on the day of your surgery.
- If you smoke, you need to stop. Ask your provider for help quitting.
- Tell your surgeon about any cold, flu, fever, herpes breakout, or other illness you may have before your surgery.
Follow instructions on when to stop eating and drinking before surgery.
On the day of your surgery:
- Take any medicines your surgeon prescribed with a small sip of water.
- Follow instructions on when to arrive at the hospital. Be sure to arrive on time.
After the Procedure
You may have a drain in your neck that goes into your incision. It will drain fluid that builds up in the area. It will be removed within a day.
After surgery, your surgeon may want you to stay in the hospital overnight so that nurses can watch you for any signs of bleeding, stroke, or poor blood flow to your brain. You may be able to go home the same day if your operation is done early in the day and you are doing well.
Follow instructions on how to take care of yourself at home.
Outlook (Prognosis)
Carotid artery surgery may help lower your chance of having a stroke. But you will need to make lifestyle changes to help prevent plaque buildup, blood clots, and other problems in your carotid arteries over time. You may need to change your diet and start an exercise program, if your provider tells you exercise is safe for you. It is also important to stop smoking.
References
Biller J, Schneck MJ, Ruland S. Ischemic cerebrovascular disease. In: Jankovic J, Mazziotta JC, Pomeroy SL, Newman NJ, eds. Bradley and Daroff's Neurology in Clinical Practice. 8th ed. Philadelphia, PA: Elsevier; 2022:chap 65.
Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Developed in collaboration with the American Academy of Neurology and Society of Cardiovascular Computed Tomography. Catheter Cardiovasc Interv. 2013;81(1):E76-E123. PMID: 23281092
Brott TG, Howard G, Roubin GS, et al. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med. 2016;374(11):1021-1031. PMID: 26890472
Perler BA. Carotid endarterectomy. In: Cameron JL, Cameron AM, eds. Current Surgical Therapy. 14th ed. Philadelphia, PA: Elsevier; 2023:1025-1031.
Perler BA. Carotid endarterectomy. In: Sidawy AN, Perler BA, eds. Rutherford's Vascular Surgery and Endovascular Therapy. 10th ed. Philadelphia, PA: Elsevier; 2023:chap 93.
Version Info
Last reviewed on: 4/16/2023
Reviewed by: Mary C. Mancini, MD, PhD, Cardiothoracic Surgeon, Shreveport, LA. Review provided by VeriMed Healthcare Network. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.
