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Carotid Endarterectomy

Carotid Endarterectomy

What is a carotid endarterectomy?

Carotid endarterectomy (CEA) is a treatment for carotid artery disease. The carotid arteries are the main blood vessels that carry oxygen and blood to the brain. In carotid artery disease, these arteries become narrowed. This reduces blood flow to the brain and could cause a stroke.

For a carotid endarterectomy, your doctor will surgically remove plaque that builds up inside the carotid artery. He or she will make an incision on the side of the neck over the affected carotid artery. The artery is opened and the plaque removed. Your doctor will stitch the artery back together, restoring normal blood flow to the brain. You may have this procedure while you are awake under local anesthesia or while you are asleep under general anesthesia.

Why might I need a carotid endarterectomy?

Narrowing of the carotid arteries is most often caused by atherosclerosis. This is a buildup of plaque in the inner lining of the artery. Plaque is made up of fatty substances, cholesterol, cellular waste products, calcium, and fibrin. Atherosclerosis, or "hardening of the arteries," can affect arteries throughout the body. Carotid artery disease is similar to coronary artery disease, in which blockages occur in the arteries of the heart, and may cause a heart attack. In the brain, it can lead to stroke.

The brain needs a constant supply of oxygen and nutrients to function. Even a brief break in blood supply can cause problems. Brain cells start to die after just a few minutes without blood or oxygen. If the narrowing of the carotid arteries becomes severe enough to block blood flow, or a piece of plaque breaks off and blocks blood flow to the brain, a stroke may occur.

You may or may not have symptoms of carotid artery disease. Plaque buildup may not be blocking enough blood flow to cause symptoms. A transient ischemic attack (TIA) or a stroke may be the first sign of disease.

Your doctor may have other reasons to recommend a carotid endarterectomy.

What are the risks of a carotid endarterectomy?

Some possible complications of carotid endarterectomy include:

  • Stroke or transient ischemic attack (TIA)
  • Heart attack
  • Pooling of blood into tissue around the incision site causing swelling
  • Nerve problems with certain functions of the eyes, nose, tongue, and/or ears
  • Bleeding into the brain (intracerebral hemorrhage)
  • Seizures (uncommon)
  • Repeated blockage of the carotid artery, or new blockage that develops in the artery on the other side of your neck
  • Bleeding
  • Infection
  • High blood pressure
  • Irregular heart beat
  • Blocked airway from swelling

If you are allergic to or sensitive to medicines, contrast dye, iodine, or latex, tell your doctor. Also tell your doctor if you have kidney failure or other kidney problems.

There may be other risks based on your condition. Be sure to discuss any concerns with your doctor before the procedure.

How do I get ready for a carotid endarterectomy?

  • Your doctor will explain the procedure to you and you can ask questions.
  • You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.
  • Your doctor will review your health history and do a physical exam to make sure you are in otherwise good health before having the procedure. You may have blood tests or other diagnostic tests.
  • Tell your doctor if you are sensitive to or are allergic to any medicines, iodine, latex, tape, contrast dye, or anesthesia.
  • Tell your doctor of all medicines (prescription and over-the-counter) and herbal supplements that you are taking.
  • Tell your doctor if you have a history of bleeding disorders or if you are taking any blood-thinning medicines (anticoagulants), aspirin, or other medicines that affect blood clotting. You may be told to stop some of these medicines before the procedure.
  • If you are pregnant or think you could be, tell your health care provider.
  • You will be asked to fast for 6 to 8 hours before the procedure, generally after midnight.
  • Your doctor may request a blood test before the procedure to find out how long it takes your blood to clot.
  • You may get a sedative before the procedure to help you relax.
  • Tell your doctor if you have a pacemaker.
  • If you smoke, stop smoking as soon as possible before the procedure. This may improve your recovery and your overall health status. Smoking increases clot formation in the blood.
  • Based on your condition, your doctor may ask for other preparation.

What happens during the carotid endarterectomy?

Carotid endarterectomy requires a stay in hospital. Procedures may vary based on your condition and your doctor's practices.

Generally, carotid endarterectomy (CEA) follows this process:

1.    You will be asked to remove any jewelry or other objects that may interfere with the procedure.

2.    You will remove your clothing and put on a hospital gown.

3.    You will be asked to empty your bladder before the procedure.

4.    An intravenous (IV) line will be started in your arm or hand. Another catheter will be put in your wrist to monitor your blood pressure and to take blood samples. One or more extra catheters may be put in into your neck, opposite the surgery site, to monitor your heart. Other sites for the catheter include the under the collarbone area and the groin.

5.    If there is too much hair at the surgical site, it may be shaved off.

6.    You will be positioned on the operating table, lying on your back, with your head raised slightly and turned away from the side to be operated on.

7.    A catheter will be put in into your bladder to drain urine.

8.    The anesthesiologist will continuously check your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.

9.    CEA may be done under local anesthesia. You will be sleepy, but will not feel the area being operated on. You will get a sedative in your IV before the procedure to help you relax. This lets the doctor monitor how you are doing during the procedure by asking you questions and testing your hand grip strength.

10. If the CEA is done under local anesthesia, the doctor will provide constant support and keep you comfortable during the procedure. You will get pain medicine as needed.

11. Under local anesthesia, you will get oxygen through a tube that fits in your nose.

12. A CEA may also be done under general anesthesia. This means you will be asleep. Once you are sedated, a breathing tube will be inserted into your throat and into your windpipe to provide airflow to your lungs. You will be connected to a ventilator, which will breathe for you during the procedure.

13. You will be given a dose of antibiotics through your IV to help prevent infection.

14. The skin over the surgical site will be cleaned with an antiseptic solution.

15. The doctor will make an incision down the side of the neck over the diseased artery. Once exposed, the doctor will make an incision into the artery.

16. ‘The doctor may use a device called a shunt to divert blood flow around the surgical area to maintain blood flow to the brain. A shunt is a small tube that is put into the carotid artery to deliver blood flow around the area being operated on.

17. With the blood flow diverted, the doctor will remove the atherosclerotic plaque from the artery.

18. The shunt will be removed and the artery will be closed. The incision in the neck will be stitched together.

19. A drain may be placed in your neck. The drain is a small tube that is put in the neck area to drain any blood into a small palm-size suction bulb. It is generally removed the morning after the procedure.

20. You may get blood pressure medicine through your IV during and after the procedure to keep your blood pressure within a certain range.

21. If you had general anesthesia, the doctor will wake you up in the operating room to be sure you can respond to questions.

22. A sterile bandage or dressing will be applied.

What happens after carotid endarterectomy?

In the hospital

After the procedure you will be taken to the recovery room. Once your blood pressure, pulse, and breathing are stable and you are alert, you may be taken to the intensive care unit (ICU) or your hospital room.

At the appropriate time, you will be helped out of bed to walk around as you can handle it.

If a drainage tube was placed in the incision during the procedure, your doctor will likely remove it the next morning.

You will be offered solid foods as you can handle them.

Take a pain reliever as recommended by your doctor. Aspirin or certain other pain medicines may increase the chance of bleeding. Be sure to take only recommended medicines.

Your doctor may schedule you for follow-up duplex ultrasound procedures to monitor the carotid arteries in your neck.

Generally, you can go home within 1 to 2 days after a carotid endarterectomy.

At home

Once you are home, it is important to keep the incision area clean and dry. Your doctor will give you specific bathing instructions. If stitches are used, they will be removed during a follow-up office visit. If adhesive strips are used, keep them dry and they will off within a few days.

You may go back to your normal diet unless your doctor tells you otherwise. It is generally advised to follow a diet that is low in fat and cholesterol. You should eat vegetables, fruits, low-fat or non-fat dairy products, and lean meats. Avoid foods that are processed or packaged.

If you used tobacco or smoked before your procedure, get help to quit. Smoking contributes to narrowing and hardening of your arteries.

Tell your doctor to report any of the following:

  • Fever or chills
  • Redness, swelling, or bleeding or other drainage from the incision site
  • Increased pain around the incision site
  • Any sudden or severe headache or a headache on the side of the surgery
  • Trouble thinking, weakness, or trouble moving including confusion, memory loss, dizziness, trouble speaking.
  • Vision changes or vision losses

Your doctor may give you other instructions after the procedure, based on your situation.

Next steps

Before you agree to the test or the procedure make sure you know:
  • The name of the test or procedure
  • The reason you are having the test or procedure
  • The risks and benefits of the test or procedure
  • When and where you are to have the test or procedure and who will do it
  • When and how will you get the results
  • How much will you have to pay for the test or procedure
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