Carotidendarterectomy

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Introduction

Introduction

Carotid endarterectomy is a surgical procedure to unblock a carotid artery. The carotid arteries are the main blood vessels that supply the head and neck.

Carotid endarterectomies are carried out when one or both carotid arteries become narrowed because of a build-up of fatty deposits (plaque). This is known as carotid artery disease or carotid artery stenosis.

If a narrowed carotid artery is left untreated, blood flow to the brain may be affected. This is usually because a blood clot forms and a piece breaks off and goes to the brain. This can result in either:

  • a stroke - a serious medical condition that can cause brain damage or death
  • a transient ischaemic attack (TIA) - sometimes known as a "mini-stroke", a TIA is similar to a stroke but the signs and symptoms are temporary and usually disappear within 24 hours

Each year around 110,000 people have a stroke in the UK and around a quarter of these are caused by a narrowing of the carotid arteries. More than 5,000 carotid endarterectomy procedures were performed on the NHS between 2011 and 2012.

Carotid endarterectomy can significantly reduce the risk of a stroke in people with severely narrowed carotid arteries. In people who have previously had a stroke or a TIA, their risk of having another stroke or TIA within the next three years is reduced by a third after surgery.

It's now thought the operation should be performed as soon as possible after symptoms appear. It's important to seek immediate medical advice if you experience symptoms such as:

  • numbness or weakness in the face, arm or leg
  • speech problems
  • loss of vision in one eye

Read more about when carotid endarterectomy is needed.

About the procedure

Carotid endarterectomy can be carried out using either local anaesthetic or general anaesthetic. The advantage of local anaesthetic is it allows the surgeon to monitor brain function while you're awake. However, there's no evidence that either is safer or better.

During the procedure, a 7-10cm (2.5-4 inch) cut will be made between the corner of your jaw and your breastbone. A small cut is then made along the narrowed section of artery, and the fatty deposits that have built up are removed.

The artery is then closed with stitches or a patch and your skin is also closed with stitches.

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What happens after the procedure

You'll usually be moved to the recovery area of the operating theatre for monitoring. Most people are well enough to go home within about 48 hours of the procedure.

In most cases, the only problems experienced after the operation are temporary numbness or discomfort in the neck.

However, there's a small risk of more serious complications, which can include stroke or death in around 3% of cases. Nevertheless, this risk is much lower than in people with carotid artery disease who haven't chosen to have the operation.

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Are there any alternatives?

Carotid endarterectomy is the main treatment for narrowing of the carotid arteries, but sometimes an alternative procedure called carotid artery stent placement may be available.

This is a less invasive procedure than a carotid endarterectomy because it doesn't involve a cut being made in the neck. Instead, a thin flexible tube is guided to the carotid artery through a small cut in the groin. A mesh cylinder (stent) is then placed into the narrowed section of artery to widen it and allow blood to flow through it more easily.

Carotid stenting is currently thought to be associated with a higher risk of stroke during the procedure, especially if it's performed in the first few days after symptoms appear. However, it's a useful alternative for people who may be at a higher risk of complications from an operation.

Read more about carotid artery stent placement.

When carotid endarterectomy is needed

When carotid endarterectomy is needed

A carotid endarterectomy may be needed if one or both of your carotid arteries become narrowed because of a build-up of fatty deposits (plaque).

This is known as carotid artery disease or carotid artery stenosis, and it significantly increases your risk of having a stroke or a transient ischaemic attack (TIA).

Why carotid artery disease develops

Normal healthy arteries are elastic and smooth on the inside, allowing blood to easily flow through them. As a person gets older, plaque can build up inside the arteries, making them narrower and stiffer. This process is called atherosclerosis.

As well as ageing, there are several other factors that can contribute to a build-up of plaque, including:

Read more about the causes of atherosclerosis.

Carotid artery disease and stroke

There are two ways a stroke or TIA could occur if the flow of blood through your carotid arteries becomes blocked or restricted. These are described below:

  • an ischaemic stroke - if the carotid artery is completely blocked and limits the blood supply to your brain
  • an embolic stroke - if a blood clot forms on the roughened surface of the carotid artery and breaks off, it may block one or more arteries in the brain

Diagnosing carotid artery disease

Carotid artery disease is usually diagnosed if a person has the symptoms of a stroke or TIA, such as the face drooping on one side, numbness or weakness in the arms or legs, speech problems, or a loss of vision in one eye.

However, narrowing of the carotid arteries may be diagnosed if you're having tests for another reason and the doctor testing you notices your arteries are narrowed. This is called an asymptomatic carotid stenosis.

If you've recently had a stroke or a TIA, you'll be referred for some brain imaging tests. This allows the blood supply to your brain to be checked and any narrowing in your carotid arteries to be diagnosed.

Several tests can be used to examine your carotid arteries and find out how much plaque has built up inside them. These include:

  • duplex ultrasound scan - sound waves are used to produce an image of your blood vessels and measure the blood flow through them; it can also show how narrow your blood vessels are
  • computerised tomography (CT) scan - a series of X-rays are taken at slightly different angles, and a computer assembles the images to create a detailed picture of the inside of your body
  • computed tomographic angiogram (CTA) - a special dye is injected into a vein and a CT machine is used to take X-rays to build up a picture of your neck arteries
  • magnetic resonance angiography (MRA) - a magnetic field and radio waves are used to produce images of your arteries and the blood flow within them

An ultrasound scan is usually used first to check if there's any narrowing in your arteries and to determine whether it's severe enough for you to benefit from having surgery.

If your arteries are narrowed, you may need to have further tests to confirm the diagnosis, such as a CTA or MRA.

Grading narrowed arteries

If tests indicate your carotid arteries are narrowed, the severity of the narrowing (stenosis) will be graded to determine if you need surgery.

In the UK, the most common grading system used is the North American Symptomatic Carotid Endarterectomy Trial (NASCET) scale. The scale has three categories:

  • minor - 0-49% narrowed
  • moderate - 50-69% narrowed
  • severe - 70-99% blocked

When is surgery recommended

The National Institute for Health and Care Excellence (NICE) recommends that people who have had a stroke or TIA and have a moderate or severe stenosis should have a carotid endarterectomy.

You should be assessed within a week of the start of your stroke or TIA symptoms, and the operation will ideally be carried out within two weeks of when your symptoms started.

It's crucial that you seek medical advice as soon as possible if you develop symptoms of a stroke or TIA. Surgery has the best chance of preventing a further stroke if it's performed as soon as possible.

Surgery will sometimes be recommended if you haven't previously had a stroke or a TIA, but you're found to have severe stenosis.

Surgery won't be recommended if you have minor stenosis (less than 50%). This is because surgery has the most benefit for people with moderate and severe stenosis (more than 50%). The maximum benefit is seen in those with severe stenosis (70-99%).

A carotid endarterectomy isn't of any benefit in people with a complete blockage of their carotid artery.

Getting ready for a carotid endarterectomy

Getting ready for a carotid endarterectomy

Before being admitted for surgery, you'll have a careful pre-operative assessment.

If a carotid endarterectomy has been arranged in advance, this assessment will usually be carried out at a hospital pre-assessment clinic a few days before you're due to have the procedure. In some cases, you'll be asked to attend the pre-assessment clinic on the day the operation is scheduled.

Alternatively, you may be seen at a specialist clinic if you've recently had a stroke or transient ischaemic attack (TIA). Tests to check the health of your arteries will be carried out, and you may be admitted for surgery immediately if your carotid arteries are found to be severely narrowed.

Pre-admission clinic

You'll have a physical examination and be asked about your medical history at a pre-admission clinic. Any further tests or investigations that are needed will also be carried out at this time.

The pre-admission clinic is a good opportunity for you to ask your treatment team about the procedure, although you can discuss any concerns you may have at any time.

If you're taking any medication (prescribed or otherwise), it would be useful to bring it with you to the pre-admission clinic so the details can be noted.

You'll be asked whether you've had anaesthetic (painkilling medication) in the past and whether you experienced any problems or side effects, such as feeling sick. You'll also be asked whether you're allergic to anything to avoid a reaction to any medication you may need during your treatment.

Your treatment team will ask you about your teeth, including whether you wear dentures, have caps or a plate. This is because during the operation you may need to have a tube put down your throat to help you breathe, and loose teeth could be dangerous.

Preparing for surgery

Before having a carotid endarterectomy, your surgeon will discuss how you should prepare. They may give you the following advice:

  • stop smoking - smoking increases your risk of developing a chest infection, can delay healing, and increase your risk of developing a blood clot
  • watch your weight - if you're overweight, losing weight will be recommended, but as strenuous exercise could be dangerous, you'll need to do this by dieting; your GP will be able to advise you about how to lose weight
  • gentle post-op exercise - being active can help your recovery, but you shouldn't overdo it; your surgeon or GP can advise you about how much you can do
  • think positive - a positive mental attitude can help you deal with the stress of surgery and aid your recovery

Read more about preparing for surgery.

How carotid endarterectomy is performed

How carotid endarterectomy is performed

A carotid endarterectomy will either be carried out under general or local anaesthesia.

Anaesthetic

Anaesthetic is painkilling medication that allows surgery to take place without a patient feeling pain or discomfort.

If you have a general anaesthetic, you'll be asleep throughout the procedure. You'll remain conscious if you have a local anaesthetic, but the area on your neck will be numbed so you can't feel any pain.

Studies comparing the results of carotid endarterectomies found no difference between the two types of anaesthetic. It will be up to you, your surgeon and your anaesthetist (specialist in anaesthesia) to decide which type of anaesthetic to use. 

Your surgeon may prefer to use local anaesthetic so you remain conscious during the operation. This allows them to monitor your brain's reaction to the decreased blood supply throughout the procedure.

The procedure

A carotid endarterectomy usually takes one to two hours to perform. If both of your carotid arteries need to be unblocked, two separate procedures will be carried out. One side will be done first and the second side will be done a few weeks later.

Once you're asleep or the area has been numbed, your neck will be cleaned with antiseptic to stop bacteria getting into the wound. If necessary, the area may also be shaved. A small cut will then be made to allow the surgeon to access your carotid artery.

During the procedure, your surgeon will decide whether to use a temporary shunt to maintain adequate blood flow to the brain. A shunt is a small plastic tube that can be used to divert blood around the section of the carotid artery being operated on. The decision to use a shunt is based on surgeon preference and the results of brain blood flow monitoring during the operation.

When the surgeon has access to the carotid artery, the artery is clamped to stop blood flowing through it and an opening is made across the length of the narrowing. If a shunt is to be used, it will be inserted now. The surgeon will then remove the inner lining of the narrowed section of artery, along with any fatty deposits (plaque) that have built up.

Once the narrowing has been removed, the opening in the artery will then either be closed with stitches or a special patch. The majority of surgeons in the UK use a patch, but the choice is down to what the surgeon prefers.

Your surgeon will then check for any bleeding. The cut in your neck will be closed after any bleeding has stopped. A small tube (drain) may be left in the wound to drain away any blood that might build up after the operation. This is usually removed the following day.

After the procedure

When the operation is finished, you'll usually be moved to the recovery area of the operating theatre, where your health can be monitored to ensure you're recovering well.

Read more about recovering from a carotid endarterectomy.

Recovering from carotid endarterectomy

Recovering from carotid endarterectomy

After a carotid endarterectomy, you'll usually be moved to the recovery area of the operating theatre or, in some cases, a high dependency unit (HDU).

An HDU is a specialist unit for people who need to be kept under close observation after surgery, usually because they have high blood pressure and need to be closely monitored.

After surgery, your breathing and heart rate will be monitored to ensure you're recovering well.

You may have some discomfort in your neck around where the incision was made. This can usually be controlled with painkillers. You may also experience numbness around the wound, which should disappear after a while.

Most people are able to eat and drink a few hours after having surgery. You'll usually be able to leave hospital and return home within 48 hours.

Wound care

The wound on your neck will be closed with stitches, which may need to be removed at a later date. Your surgeon will be able to advise you about this. Sometimes dissolvable stitches or skin glue are used instead.

Your surgeon will also be able to give you advice about caring for your wound. This will usually be a simple matter of keeping it clean using mild soap and warm water.

You may be left with a small scar running from the angle of your jaw to the top of your breastbone. The scar is usually about 7-10cm (2.5-4 inches) long and fades to a fine line after two or three months.

Driving

Your GP will be able to advise you about when it's safe to drive after surgery - usually when you can safely carry out an emergency stop. For most people, this is between two to three weeks after the operation.

If you've had a stroke or transient ischaemic attack (TIA), you won't be allowed to drive for a month afterwards. If you've fully recovered, you don't need to inform the DVLA unless you drive a lorry or a bus for a living.

Work and exercise

Most people are able to return to work three to four weeks after having a carotid endarterectomy. Your surgeon or GP will be able to advise you further about returning to work.

You may be advised to limit physical activity for a few weeks after having surgery. This includes manual labour and playing sports. If your job involves manual labour, you should only perform light duties until you've fully recovered.  

Risks of carotid endarterectomy

Risks of carotid endarterectomy

As with all types of surgery, there are risks associated with having a carotid endarterectomy.

The two main risks are:

  • stroke - the risk of stroke is around 2%, although this may be higher in people who had a stroke before the operation
  • death - there's a less than 1% risk of death, which can occur as a result of complications such as a stroke or heart attack

Most strokes that occur after carotid endarterectomy are caused by an artery in the brain becoming blocked during the early postoperative period, or because there's some bleeding into the brain tissue.

This may happen if the procedure causes a blood clot to move and block an artery. Your surgical and anaesthetic team will do all they can to prevent this.

Other complications

As well as stroke and death, there's a small chance of developing other complications after having a carotid endarterectomy. These include:

  • pain or numbness at the wound site - this is temporary and can be treated with painkillers
  • bleeding at the site of the wound
  • wound infection - the wound where the incision was made can get infected; this affects less than 1% of people and is easily treated with antibiotics
  • nerve damage - this can cause a hoarse voice and weakness or numbness on the side of your face; it affects around 4% of people, but is usually temporary and disappears within a month
  • narrowing of the carotid artery again - this is called restenosis; further surgery is required in about 2-4% of people

Your surgeon should explain the risks associated with a carotid endarterectomy before you have the procedure. Ask them to clarify anything you're not sure about and answer any concerns you have. 

Increased risk

Factors that increase your risk of experiencing complications because of a carotid endarterectomy include:

Alternatives to carotid endarterectomy

Alternatives to carotid endarterectomy

Carotid endarterectomy is the main treatment for narrowing of the carotid arteries as it's very effective.

However, there's also an alternative procedure called carotid artery stent placement, or "stenting".

Carotid artery stent placement

Carotid artery stent placement is less invasive than a carotid endarterectomy because it doesn't involve a cut being made in the neck.

Stenting is carried out under local anaesthetic and involves a narrow flexible tube called a catheter being inserted into an artery in your groin. It's then threaded up into the carotid artery using X-rays to guide it into place.

A small balloon at the end of the catheter is inflated to around 5mm at the site of the narrowed artery, and a small mesh cylinder called a stent is then inserted. The balloon will be deflated and removed, leaving the stent in place to keep the artery open and allow blood to flow through it.

After the procedure, you'll need to lie flat and keep still for about an hour to prevent any bleeding from the artery. You'll need to stay in hospital overnight, but will be able to return home the next day.

Like carotid endarterectomy, there are some risks associated with stenting. The risk of having another stroke or dying is slightly higher than after carotid endarterectomy, especially when the procedure is performed soon after symptoms appear. But the long-term outcomes from a successful procedure are no different from a carotid endarterectomy.

The decision about which procedure you'll have will be made based on your own personal wishes, your overall fitness, and an assessment of your clinical history. One major factor is how long it's been since your most recent symptom.

NICE guidelines

The National Institute for Health and Care Excellence (NICE) has confirmed stenting is a safe procedure and has good short-term results.

Evidence suggests a successful stent procedure has the same long-term risks of a stroke as carotid endarterectomy.

NICE advises that, provided the risks of stenting are judged similar to those after surgery, it's safe to offer this alternative. 

Read the NICE guidance on carotid artery stent replacement for symptomatic extracranial carotid stenosis.

'I'm able to walk again'

'I'm able to walk again'

Mr Joseph Leverment, from Cropston, Leicester, had a carotid endarterectomy while he was a senior surgeon at University Hospitals of Leicester NHS Trust. He was operated on by colleagues at Leicester Royal Infirmary after having a transient ischaemic attack (TIA) at work.

"I was doing my outpatient clinic at Glenfield Hospital near Leicester when suddenly I felt nauseous and dizzy. I didn't think much of it to begin with and took a break to have a cup of tea. When that didn't help, I thought I might have low blood sugar as I hadn't eaten much that morning. I went to the hospital fast food restaurant to get something to eat. It was only at the counter that I realised I couldn't speak.

"Being a medical professional, I had an idea something might be wrong, but in confusion I thought I should just go home and rest. Once home, I went to bed and although it was the middle of the day, I slept for hours. When I woke up, my wife noticed at once that I was very confused as I was unable to string a proper sentence together.

"By then I had realised that I needed urgent medical help. As I couldn't speak properly, I managed to write down the name of one of my colleagues, a fellow surgeon, on a piece of paper. Although I had worked with him for years and he was a good friend, all I could remember was his first name, Graham. My wife understood immediately who she should contact. She drove me to the hospital where Graham was. On getting out of my bed, I realised I couldn't feel my right arm or leg. I became increasingly worried.

"At the hospital, I had an MRI scan and other tests, which showed I had almost a total blockage on the left carotid artery. I was then transferred to Leicester Royal Infirmary where I had a carotid endarterectomy the following morning. I knew I had no option but to have the surgery. It was urgent as I was having what is called 'crescendo' TIAs, where I was likely to have a major stroke at any time. I had full confidence in the surgeon who did the operation as I'd known him professionally for years.

"When I woke up I was so grateful to see my wife and daughter's faces again - I realised there was a small risk I would have a stroke and perhaps not survive the operation. I felt reasonably well afterwards, but still had numbness down my right side. My arm and leg were badly affected. My speech was also not back to normal. But after spending the night in intensive care, I was well enough to go home again the following morning.

"For several weeks after the operation I had naps in the afternoon as I got tired very easily, mentally and physically. Now, five months on, I am much improved. I can speak again. For a time, even though able to talk, I was getting words mixed up and not making a lot of sense. This was caused by damage to part of my brain during the TIAs.

"I have also gradually regained my strength. I began by doing small things around the house, like potting plants and doing a few odd jobs. Since then I have progressed to full-on gardening. I'm currently building a barbecue, which we will use in the summer. I can also walk again, and I've regained use of my hand.

"I've also made a lot of lifestyle changes. I've been a smoker since I was 18 and only stopped after my surgery. My colleagues used to call me 'Smokey Joe'. It was hard to give up smoking even then, but I succeeded with the help of nicotine replacement therapy. I had patches, an inhaler and nicotine gum!

"I've changed my diet too. With such a busy life, I often ate fast food on the go. I also used to eat a lot of red meat. Now we eat a lot more vegetables. Instead of a fry-up in the morning, we have porridge. That wasn't an easy change as I was very fond of red meat and fatty foods. But I know how important it is for the health of my arteries.

"I'm taking several different types of medication to keep my cholesterol under control. Unfortunately, high cholesterol runs in my family. I'm also on blood pressure medication and still struggle at times to keep that normal. Thankfully I have a wonderful GP who is very helpful. Another tablet I take every day is aspirin to help stop blood clots.

"The tests showed that my other carotid artery has only a 30% blockage, so I thankfully won't need to have surgery on that one.

"As I was already over retirement age, I won't be going back to work again. I consider myself to be very lucky. Because of my medical background, I had a good idea of what was happening to me on that day in November. I also knew exactly who to contact. I know others aren't so fortunate. Not everyone knows the symptoms of a stroke or a TIA."