What is this?
A carotid endarterectomy is an operation performed to unblock the artery in the neck (carotid artery) that supplies blood to the brain thereby reducing your risk of stroke.
Why do I need this?
You will be offered this operation if you have suffered from a TIA or a stroke, in the recent past, or are at risk of stroke in the future as a result of carotid artery disease. Approximately 110,000 people suffer a stroke in the UK each year and about a quarter of these are caused by a carotid artery stenosis. The operation is not performed to correct the symptoms of a TIA or stroke but to prevent any further episodes in the future.
What happens during the operation?
The main aim of the operation is to clear the carotid artery of plaque. This can be performed using a local or general anaesthetic. In our practice, general anaesthetic is preferred as it allows for a more controlled environment throughout the operation. You may have several drips inserted into your arms to monitor your blood pressure during the operation and a small probe placed on the side of your head to monitor blood flow to the brain.
An incision is made in the neck between your ear and breastbone, usually about 10cm long. The artery lies deep in the neck and to access it, veins and lymphatics must be divided. Several important nerves in the neck overly the artery. These are identified and gently retracted out of the field of view. The artery is then isolated. You will receive an intravenous blood thinner called heparin before clamps are applied to your artery. The artery is then opened longitudinally and a shunt is placed in the opening. This is a plastic tube that allows blood to flow to the brain and excludes the diseased area so that the operation can be performed in a bloodless field. The plaque is then removed and the artery repaired by stitching an artificial patch, usually made of tissue from a cow, to cover the hole.
The shunt is then removed and flow is restored to the brain. A plastic tube called a drain is inserted into the wound at the end of the procedure and connected to an external bottle. The skin is repaired with dissolvable stitches or skin staples.
What happens after the operation?
After the operation, optimal blood pressure control is key. This will initially be monitored through the drip in your arm and then eventually in the usual way using a blood pressure monitor. The drain will be removed at 24 hours if there is minimal drainage and you will be encouraged to mobilise. Your neck will feel stiff and sore which is normal. There may be some numbness around the wound which may be permanent. If you remain well with a normal blood pressure you will be discharged in 48 hours.
What the risks from the operation?
The main risks from the operation include a small 3% risk of stroke during the operation itself. There is also a similar rate of nerve damage from the surgery. The 2 main nerves affected control the strength of your voice, swallowing and tongue movements. These nerves are identified during the surgery and moved but can become stretched and bruised, in which case the symptoms are usually temporary (2-4 months). This may cause hoarseness to your voice or a lack of coordinated swallowing. Sometimes these functions are recoverable with physiotherapy.
There is also a small (1%) risk of patch infection and death from the surgery. Patch infections are very difficult to treat and usually require further surgery to remove the patch and replace it with your own vein.
As the operation constitutes major vascular surgery, there is also a small risk of chest infections, pneumonia, heart attack and other complications associated with major surgery.
The minor side effects include feeling tired for up to 8 weeks after the operation. You may also have some numbness around the scar, ear or face which is due to division of skin nerves. Usually this settles but it can be permanent.
Are there any other options for treatment?
The 2 main alternatives to surgery are medical therapy and stenting:
This includes continuing the oral blood thinning medication, a statin tablet, and controlling your blood pressure, diabetes and other risk factors. The predicted risk of suffering further TIA or stroke can be calculated using scoring systems, although it must be remembered that this is only an estimate. Risks from surgery are generally lower than simply using medical management.
Carotid artery stenting:
This involves placing a stent in the diseased area to widen the artery. It is performed under a local anaesthetic and involves a needle puncture to the artery in the groin or arm, followed by x-ray guided stent placement in the neck. There is some evidence to suggest that this procedure is associated with a higher stroke rate and is therefore not offered as first line treatment. However, it is a useful alternative in those patients who are at higher risk of complications from surgery.
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What should I do next?
If you think you have one of these conditions or any of the described symptoms we recommend you seek medical advice.