Carotid Endarterectomy

What are the carotid arteries?

The main supply of blood to the brain is carried by the carotid arteries. The carotid arteries branch off from the aorta (the largest artery in the body) a short distance from the heart, and extend upward through the neck carrying oxygen-rich blood to the brain.

There are six carotid arteries: the right and left carotid arteries divide to provide the right and left internal carotid arteries and the right and left external carotid arteries. One pair (external and internal) is located on each side of the neck. Just as a pulse can be felt in the wrists, a pulse can also be felt on either side of the neck over the carotid arteries.

Why are the carotid arteries important?

Because the carotid arteries deliver blood to the brain, carotid artery disease can have serious implications by reducing the flow of oxygen and nutrients to the brain. The brain needs a constant supply of oxygen and nutrients in order to function. Even a brief interruption in blood supply can cause problems. Brain cells begin 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 atherosclerotic plaque breaks off and obstructs blood flow to the brain, a stroke may occur.

Unfortunately, there may be no symptoms of early carotid artery disease. An abnormal sound called a bruit (pronounced brew-ee) may be heard by a stethoscope placed on the carotid arteries in the neck. A bruit is an abnormal sound that is produced by blood passing through a narrowed artery. A bruit is generally considered a sign of an atherosclerotic artery; however, an artery may be diseased without producing a bruit. If the disease continues to progress until sufficient artery blockage exists, problems may occur, such as a stroke. Because brain tissue cannot be regenerated (replace itself), stroke prevention is the goal of treatment.

What are the surgical treatments of carotid artery disease?

There are two procedures used to treat carotid artery disease. The standard surgical procedure is carotid endarterectomy (CEA), while the newer minimally invasive endovascular intervention is called carotid artery angioplasty with stenting (CAS).

Carotid endarterectomy. In a carotid endarterectomy, atherosclerotic plaque that has built up on the inside of the carotid artery wall is surgically removed. An incision is made on the side of the neck where the affected carotid artery is located. Under direct visualization, the artery is opened and the plaque removed. The artery is sutured back together, restoring normal blood flow to the brain. This procedure may be performed while a patient remains awake under local anesthesia or while the patient is asleep under general anesthesia.

Carotid artery angioplasty with stenting (CAS). Carotid artery angioplasty with stenting (CAS) is a minimally invasive procedure requiring only a small incision in the groin. A special catheter (long hollow tube) is inserted into the carotid artery to be treated. This catheter has a tiny balloon at its tip. The balloon is inflated once the catheter has been placed into the narrowed area of the carotid artery. The inflation of the balloon compresses the fatty tissue in the artery and makes a larger opening inside the artery for improved blood flow. A stent (a tiny, expandable metal coil) may be inserted into the newly-opened area of the artery to help keep the artery from narrowing or closing again.
Because of the potential for clots (emboli) to dislodge from the plaque into the circulation of the brain and possibly cause a stroke, there are now devices called embolic protection devices (EPD) being used during CAS. One type of EPD has a filter-like basket attached to a catheter that is positioned in the artery so as to "catch" any clots or small debris that might break loose from the plaque during the procedure. This technique may help reduce the incidence of stroke during carotid angioplasty.

Your doctor will determine the most appropriate intervention for treating your carotid artery disease.

Other related procedures that may be used to diagnose carotid artery disease include carotid artery duplex scan and cerebral arteriogram. Please see these procedures for additional information.

Why are these surgical treatments done?

Carotid endarterectomy may be performed to treat a blockage or narrowing of the carotid arteries, thus improving blood supply to the brain. Carotid endarterectomy has been shown to be effective for preventing stroke in carotid artery disease.

Carotid artery angioplasty with stenting (CAS) is a procedure currently being used on selected patients who are at high risk for surgery. While this procedure is performed widely, the long-term effects are still being studied.

High risk conditions under which CAS may be considered include, but are not limited to, the following:

• Older age

• Coronary artery disease or pending open heart surgery

• Heart failure

• Heart valve disease

• Heart arrhythmias

• Angina or heart attack within the last six months

• Cancer

• Carotid artery disease in more than one carotid artery

• Location of the blockage in the carotid artery

• Carotid artery stenosis (narrowing) caused by radiation, previous surgery on the neck, or severe chronic obstructive pulmonary disease (COPD)

Carotid artery disease may be asymptomatic (without symptoms) or symptomatic (with symptoms). Asymptomatic carotid disease is the presence of a significant amount of atherosclerotic plaque buildup in the carotid arteries without obstructing blood flow enough to cause symptoms. Symptomatic carotid artery disease may result in either a transient ischemic attack (TIA) and/or a stroke (brain attack).

The decision to treat carotid artery disease is based on certain criteria such as, but not limited to, the following:

• Symptomatic and asymptomatic carotid artery disease with blockage greater than 70 percent in the internal carotid artery is usually treated surgically.

• Asymptomatic and symptomatic carotid artery disease with blockage of 50 percent to 69 percent (with results from diagnostic tests indicating blockage closer to 69 percent) may require surgical treatment. Risk factors associated with carotid artery disease are taken under consideration when determining the need for surgery.

• Asymptomatic and symptomatic carotid artery disease with blockage of 50 percent to 69 percent (and results of diagnostic tests indicating blockage closer to 50 percent) may be treated medically, depending on the individual situation.

• Asymptomatic and symptomatic carotid artery disease with blockage of less than 50 percent are generally treated medically.

Choice of treatment, such as carotid endarterectomy, carotid artery angioplasty with stenting, or medical treatment will be determined by your doctor.

There may be other reasons for your doctor to recommend a carotid endarterectomy or carotid artery angioplasty with stenting.

What are the risks of the procedure?

As with any surgical procedure, complications can occur. Some possible complications of both carotid endarterectomy and carotid angioplasty with stenting may include, but are not limited to, the following:

• Stroke or transient ischemic attack (TIA)

• Heart attack (myocardial infarction)

• Wound hematoma (pooling of blood into surrounding tissue causing swelling)

• Cranial nerve deficits (problems with certain functions of the eyes, nose, tongue, and/or ears that are controlled by one or more of the 12 cranial nerves)

• Intracerebral hemorrhage (bleeding into the brain)

• Seizures (bursts of abnormal electrical signals that temporarily interrupt normal electrical brain function), which is an uncommon complication

• Repeated blockage of the carotid artery

• Bleeding

• Infection

• Hypertension (high blood pressure)

• Arrhythmias (irregular heart beat)

• Airway obstruction from swelling

• Stent ingrowth (overgrowth of tissue where the stent is placed which may cause a blockage) in CAS procedures

You may want to ask your doctor about the amount of radiation used during the procedure and the risks related to your particular situation. It is a good idea to keep a record of your past history of radiation exposure, such as previous scans and other types of X-rays, so that you can inform your doctor. Risks associated with radiation exposure may be related to the cumulative number of X-ray examinations and/or treatments over a long period of time.

There is a risk for allergic reaction to the dye used in a CAS procedure. Patients who are allergic to or sensitive to medications, contrast dye, iodine, or latex should notify their doctor. Also, patients with kidney failure or other kidney problems should notify their doctor.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Before the procedure

• Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.

• 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.

• In addition to a complete medical history, your doctor may perform a complete physical examination to ensure you are in good health before undergoing the procedure. You may undergo blood tests or other diagnostic tests.

• Notify your doctor if you are sensitive to or are allergic to any medications, iodine, latex, tape, contrast dye, or anesthetic agents (local and general).

• Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are taking.

• Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop some of these medications prior to the procedure.

• If you are pregnant or suspect that you are pregnant, you should notify your health care provider.

• You will be asked to fast for eight hours before the procedure, generally after midnight.

• Your doctor may request a blood test prior to the procedure to determine how long it takes your blood to clot.

• You may receive a sedative prior to the procedure to help you relax.

• Notify your doctor if you have a pacemaker.

• If you smoke, you should stop smoking as soon as possible prior to the procedure. This may improve your chances for a successful recovery from surgery and benefit your overall health status, as smoking increases clot formation in the blood.

• If your doctor determines that carotid artery angioplasty with stenting is the appropriate treatment for your carotid artery disease, you may be started on medication to help prevent more blockage in the carotid arteries such as aspirin and clopidogrel (Plavix) before the procedure.

• Based on your medical condition, your doctor may request other specific preparation.

During the procedure

Both carotid endarterectomy and carotid angioplasty with stenting require a stay in hospital. Procedures may vary depending on your condition and your doctor's practices.

Carotid endarterectomy

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 be asked to remove your clothing and will be given a gown to wear.

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

4. An intravenous (IV) line will be started in your arm or hand. An additional catheter will be inserted in your wrist to monitor your blood pressure, as well as for obtaining blood samples. One or more additional catheters may be inserted into your neck, opposite the surgery site, to monitor your heart function. Alternate sites for the additional catheter include the subclavian (under the collarbone) area and the groin.

5. If there is excessive hair at the surgical site, it may be clipped 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 inserted into your bladder to drain urine.

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

9. CEA may be performed under local anesthesia. You will be sleepy, but will not feel the area being operated on. You will receive a sedative medication in your IV before the procedure to help you relax. However, you will remain awake, but sleepy, during the procedure. This allows the physician to monitor how you are doing during the procedure by asking you questions and testing your hand grip strength.

10. If the CEA is performed under local anesthesia, the doctor will provide constant support and keep you comfortable during the procedure. Pain medicine will be administered.

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

12. A CEA may also be performed under general anesthesia (you will be asleep). Once you are sedated, a breathing tube will be inserted through your throat into 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 cleansed with an antiseptic solution.

15. The doctor will make an incision (cut) down the side of the neck over the diseased artery. Once the carotid artery is 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 inserted 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 sutured together.

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

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

21. If you received 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.

Carotid angioplasty with stenting (CAS)

Generally, a CAS procedure follows this process:

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

2. You will be asked to remove your clothing and will be given a gown to wear.

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

4. An intravenous (IV) line will be started in your arm or hand. An additional catheter will be inserted in your wrist to monitor your blood pressure, as well as for obtaining blood samples. One or more additional catheters may be inserted into your neck to monitor your heart function. Alternate sites for any additional catheters include the subclavian (under the collarbone) area and the groin.

5. If there is excessive hair at the surgical site, it may be clipped off.

6. You will be placed in a supine (on your back) position on the operating table or on a procedure table in a radiology suite.

7. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. The groin area (or arm) will be cleaned with antiseptic soap.

8. CAS is usually performed under local anesthesia. You will not feel the area being operated on. You will receive a sedative medication in your IV before the procedure to help you relax. However, you will likely remain awake, but sleepy, during the procedure.

9. The insertion area in the groin will be covered with sterile towels and a sheet.

10. A numbing medication (lidocaine or xylocaine) will be injected into the skin over the groin area. You may feel some stinging at the site for a few seconds after the numbing medication has been injected.

11. Once the numbing medication has taken effect, a sheath, or introducer, will be inserted into the blood vessel. A sheath is a plastic tube through which the catheter will be inserted into the blood vessel and advanced to the carotid artery. If the arm is used, a small incision (cut) will be made in the inner elbow area to expose the blood vessel for insertion of the sheath.

12. It will be very important for you to remain still during the procedure so that the catheter placement is not disturbed and to prevent damage to the groin (or arm) at the insertion site.

13. The angioplasty catheter will be inserted through the sheath into the blood vessel. The doctor will advance the catheter through the blood vessel into the carotid artery. A special type of X-ray, called fluoroscopy (like an X-ray "movie"), may be used to verify the location of the catheter inside the body.

14. The catheter will be advanced up towards the heart and the carotid arteries. Once the catheter is in place, dye will be injected through the catheter in order to see the narrowed area(s). You may feel a brief sensation of warmness just after the dye is injected, but this sensation is temporary and will soon pass.

15. The doctor will observe the carotid arteries after the X-ray dye injection on a monitor. X-ray pictures will be taken.

16. In order to protect the brain from pieces of plaque that may break off and travel to the brain, a device called an emboli prevention device (EPD), or cerebral protection device, will be used. One type of EPD has a filter-like basket attached to a catheter that is positioned in the artery so as to "catch" any clots or small debris that should break loose from the plaque during the procedure.

17. After the narrowed portion of the artery is located, the angioplasty catheter will be advanced to that location and the balloon will be inflated to open the artery.

18. A stent may be placed in order to keep the artery open. A stent is a tiny, cylinder-like tube made of thin metal mesh framework. The stent will be in a collapsed position until after it is inserted, advanced up into the aorta, and placed in the carotid artery. The stent will expand (in a spring-like fashion), attaching to the wall of the carotid artery.

19. Another X-ray picture will be taken to verify the position of the stent.

20. The angioplasty catheter will be removed. However, the sheath may be left in for several more hours. Alternatively, the doctor may remove the entire catheter system and place a special device called a vascular closure device at the catheter insertion site. This device helps to prevent bleeding at the insertion site.

21. You will be assisted to slide from the table onto a stretcher so that you can be taken to the recovery area.

After the procedure

In the hospital—carotid endarterectomy

After the procedure you will be taken to the recovery room for observation. 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 assisted out of bed to walk around as tolerated.

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

Your diet will be advanced to solid foods as tolerated.

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

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

Generally, patients are able to go home within one to two days following a carotid endarterectomy.

In the hospital—carotid angioplasty with stenting

After the procedure you will be taken to the recovery room for observation. 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.

NOTE: You will not be allowed to bend your leg nearest the insertion site, if the insertion was done in the groin, for several hours. To help you remember to keep your leg straight, the knee of the affected leg may be covered with a sheet and the ends tucked under the mattress on both sides of the bed to form a type of loose restraint.

A nurse will monitor your vital signs, your neurological signs, and the injection site while you are in the recovery room.

You may be given pain medication for pain or discomfort related to the injection site or having to lie flat and still for a prolonged period.

If the sheath was left in the insertion site, it will be removed from the groin or arm at the appropriate time. After the sheath is removed, pressure will be applied directly on the site either manually or with a clamp-type device for about 20 minutes. After bleeding has stopped completely with the pressure application, a tight dressing will be applied on the site. You will continue to lie in bed for a specified period, at least two hours or longer. It is very important that you keep your leg or arm with the catheter site straight during this period.

After the specified period of bed rest has been completed, you may get out of bed. The nurse will assist you the first time you get up, and will check your blood pressure while you are lying, sitting, and standing.

You may be discharged from the hospital the next day depending on your progress.

At home—carotid endarterectomy

Once you are home, it is important to keep the incision area clean and dry. Your physician 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, they should be kept dry, and generally will fall off within a few days.

You may resume your normal diet unless your doctor advises you differently.

Notify your doctor to report any of the following:

• Fever and/or chills

• Redness, swelling, or bleeding or other drainage from the incision site

• Increased pain around the incision site

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

At home—carotid angioplasty with stenting

Once at home, you should monitor the injection site for bleeding. A small bruise is normal, as is an occasional drop of blood at the site.

If the groin or arm was used, you should monitor the leg or arm for changes in temperature or color, pain, numbness, tingling, or loss of function of the limb.

You may be advised not to do any strenuous activities or take a hot bath or shower for a period of time after the procedure.

Your doctor may want to schedule you for follow-up duplex ultrasound, magnetic resonance imaging (MRI), or computed tomography (CT) scans to monitor the carotid arteries in your neck for a prescribed period of time.

MRI is a diagnostic procedure used for many different conditions. Because of the magnet used in the MRI machine, the presence of metal in or on a patient can affect the quality of the test. If you receive a stent, you may still undergo MRI without damage to your stent. Your doctor will most likely suggest that you not undergo an MRI for a month or so after your procedure unless there is an emergency situation.

Notify your doctor to report any of the following:

• Fever and/or chills

• Increased pain, redness, swelling, or bleeding or other drainage from the groin injection site

• Coolness, numbness and/or tingling or other changes in the affected extremity

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.