Carotid artery surgery

Answer 1

Definition

Carotid artery surgery is a procedure to restore proper blood flow to the brain.

Alternative Names

Carotid endarterectomy; CEA; Carotid angioplasty and stenting; CAS; Endarterectomy - carotid artery; Angioplasty - carotid artery; Percutaneous transluminal angioplasty - carotid artery; PTA - carotid artery; Angioplasty - carotid artery

Description

You have an artery on each side of your neck called the carotid artery. This artery brings needed blood to your brain and face.

The blood flow in this artery can become partly or totally blocked by fatty material called plaque. A partial blockage is called carotid artery stenosis (narrowing). Blockage in your carotid artery can reduce the blood supply to your brain. A stroke can occur if your brain does not get enough blood.

• Sometimes the plaque may close off the artery enough to cause a stroke.
• Other times a blood clot may form in the artery, block the narrow part, and stop blood from reaching the brain. This type of clot is called a thrombus. It stays in one place.
• Other times, the clot can travel and get stuck in a smaller blood vessel in the brain. A clot that travels like this is called an embolism.

There are 2 ways to treat a carotid artery that has plaque buildup in it. One is surgery called endarterectomy. The other is a procedure called angioplasty with stent placement.

During carotid endarterectomy:

• You will probably receive general anesthesia. This will make you unconscious and unable to feel pain. Some hospitals may use local anesthesia instead. With local anesthesia, only the part of your body being worked on will be made numb with medicine so that you will not feel pain.
• You will lie on your back on a padded operating table with your head turned to one side. The side that will face up is the side your blocked carotid artery is on.
• Your surgeon will make an incision (a cut) on your neck over your carotid artery. Your surgeon will put a catheter (a flexible tube) in place. Blood will flow through the catheter around the blocked area during surgery.
• Then your surgeon will open your carotid artery. The surgeon will then remove the plaque inside your artery.
• Your artery will be closed up with stitches after the plaque is removed. Blood will now flow through the artery to your brain.
• Your heart and brain activity will be monitored closely during your surgery.

Carotid angioplasty and stenting (CAS) is a less invasive way to repair the blockage in your carotid artery:

• Your surgeon will make an incision in your groin after using some numbing medicine. You will also be given medicine to relax you.
• Your surgeon will insert a catheter (a flexible tube) through the incision into an artery. The doctor will carefully guide the catheter up to your neck to the blockage in your carotid artery.
• Your surgeon will use live x-ray pictures to see your artery. This kind of x-ray is called fluoroscopy.
• Next your surgeon will pass a guide wire through the catheter to the blockage. Another catheter with a very small balloon on the end will be pushed over the guide wire and into the blockage. Then the balloon will be blown up. The balloon then presses against the inside wall of your artery. This opens the artery and restores proper blood flow to your brain.
• A stent (a wire mesh tube) may also be placed in the blocked area. The stent is inserted at the same time as the balloon catheter. It expands when the balloon is blown up. The stent is left in place to help keep the artery open. The surgeon then removes the balloon.

Why the Procedure Is Performed

There are several ways your doctor may know you have narrowing or blockage in your carotid artery. Two common ones are:

• You may have had symptoms of a stroke or a transient ischemic attack (TIA, also called a "mini-stroke"). Some of these symptoms are weakness, blurred vision, confusion, or slurred speech.
• You may not have any symptoms, but your doctor may find a problem during a physical exam. Your doctor may hear something called a bruit when using a stethoscope to listen to your blood flow. A bruit is an abnormal sound in your artery.

Your doctor will need to do one or more tests to see how blocked one or both of your carotid arteries are.

If you have had a stroke, your doctor will consider whether treating your blocked artery is safe for you. Your doctor will compare your risk of having another stroke if you do not have surgery with the risk of having serious problems from the surgery itself. Your doctor must consider:

• How bad the narrowing in your carotid arteries is
• What symptoms you have
• What other medical problems you may have
• Your age

Treatment options your doctor will discuss with you are:

• No treatment, other than checking your carotid artery with tests every year
• Medicine and diet to lower your cholesterol
• Tests to check your carotid artery and blood-thinning medicines to lower your risk of stroke. Some of these medicines are aspirin, clopidogrel (Plavix), and warfarin (Coumadin).
• Surgery to remove the buildup in your carotid artery

Most times, patients who have carotid angioplasty and stenting to treat severe narrowing of their carotid artery have this procedure because carotid endarterectomy would not be safe for them.

Risks

The risks for any anesthesia are:

• Allergic reactions to medicines
• Breathing problems

The risks for any surgery are:

• Bleeding
• Infection

Risks of carotid surgery are:

• Blood clots or bleeding in the brain
• Brain damage
• Stroke (this is rare)
• Heart attack
• Seizures (this is rare)
• Swelling near your airway (the tube you breathe through)
• Allergic reaction to dye (only with carotid artery angioplasty)
• More blockage of the carotid artery over time

Before the Procedure

Your doctor will do a thorough physical exam and several medical tests.

Always tell your doctor or nurse what drugs you are taking, even drugs, supplements, or herbs you bought without a prescription.

During the 2 weeks before your surgery:

• You may be asked to stop taking drugs that make it harder for your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), clopidogrel (Plavix), naprosyn (Aleve, Naproxen), and other drugs like these.
• Ask your doctor which drugs you should still take on the day of your surgery.
• If you smoke, you need to stop. Ask your doctor or nurse for help quitting.
• Always let your doctor know about any cold, flu, fever, herpes breakout, or other illness you may have before your surgery.

Do NOT drink anything after midnight the night before your surgery, including water.

On the day of your surgery:

• Take your drugs your doctor told you to take with a small sip of water.
• Your doctor or nurse will tell you when to arrive at the hospital.

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 doctor 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.

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 doctor tells you exercise is safe for you.

References

Chaturvedi S, Bruno A, Feasby T, Holloway R, Benavente O, Cohen SN, et al. Carotid endarterectomy -- an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2005;65:794-801.

Goldstein LB. Prevention and management of stroke. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa: W.B. Saunders; 2007:chap 58.

Mas JL, Chatellier G, Beyssen B, Branchereau A, Moulin T, Becquemin JP, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med. 2006;355(16):1660-1671.

Eckstein HH, Ringleb P, Allenberg JR, et al. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Lancet Neurol. 2008;7(10):893-902.

Answer 2

Definition

Carotid artery surgery is a procedure to restore proper blood flow to the brain.

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. Such a blockage can reduce the blood supply to your brain and may cause a stroke.

There are two invasive ways to treat a carotid artery that has plaque buildup in it. This article focuses on a surgery called endarterectomy.

For more information on the other procedure, see: Angioplasty with stent placement.

Alternative Names

Carotid endarterectomy; CAS surgery; Carotid artery stenosis - surgery; Endarterectomy - carotid artery

Description

During carotid endarterectomy:

• You will probably receive general anesthesia. This will make you unconscious and unable to feel pain. Some hospitals may use local anesthesia instead. Only the part of your body being worked on will be made numb with medicine so that you will not feel pain. You will be given a medicine to help you relax.
• You will lie on your back on a padded operating table with your head turned to one side. The side that will face up is the side your blocked carotid artery is on.
• Your surgeon will make a surgical cut on your neck over your carotid artery. Your surgeon will put a catheter (a flexible tube) in place. Blood will flow through the catheter around the blocked area during surgery.
• Then your surgeon will open your carotid artery. The surgeon will remove the plaque inside your artery.
• Your artery will be closed up with stitches after the plaque is removed. Blood will now flow through the artery to your brain.
• Your heart and brain activity will be monitored closely during your surgery.

Why the Procedure Is Performed

There are several ways your doctor may know you have narrowing or blockage in your carotid artery. Two common ones are:

• You may have had symptoms of a stroke or a transient ischemic attack (TIA, also called a mini-stroke). Some of these symptoms are weakness, blurred vision, confusion, or slurred speech.
• You may not have any symptoms, but your doctor may find a problem during a physical exam. Your doctor may hear something called a bruit when using a stethoscope to listen to your blood flow. A bruit is an abnormal sound in your artery.

Your doctor will need to do one or more tests to see how blocked one or both of your carotid arteries are.

Treatment options besides surgery that your doctor will discuss with you are:

• No treatment, other than checking your carotid artery with tests every year
• Medicine and diet to lower your cholesterol
• Tests to check your carotid artery and blood-thinning medicines to lower your risk of stroke. Some of these medicines are aspirin, clopidogrel (Plavix), and warfarin (Coumadin).

Surgery or angioplasty to remove the buildup in your carotid artery may be done if the carotid artery is narrowed by more than 70%, or if the narrowing is between 50% and 70% and your doctor feels that you have a very high risk of having a stroke.

If you have had a stroke, your doctor will consider whether treating your blocked artery with surgery is safe for you. Your doctor will compare your risk of having another stroke if you do not have surgery with the risk of having serious problems from the surgery itself.

Carotid angioplasty and stenting is more likely to be used when carotid endarterectomy would not be safe.

Risks

The risks for any anesthesia are:

• Allergic reactions to medicines
• Breathing problems

The risks for any surgery are:

• Bleeding
• Infection

Risks of carotid surgery are:

• Blood clots or bleeding in the brain
• Brain damage
• Heart attack
• More blockage of the carotid artery over time
• Seizures (this is rare)
• Stroke (this is rare)
• Swelling near your airway (the tube you breathe through)

Before the Procedure

Your doctor will do a thorough physical exam and several medical tests.

Always tell your doctor or nurse what drugs you are taking, even drugs, 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 drugs that make it harder for your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), clopidogrel (Plavix), naprosyn (Aleve, Naproxen), and other drugs like these.
• Ask your doctor which drugs you should still take on the day of your surgery.
• If you smoke, you need to stop. Ask your doctor or nurse for help quitting.
• Always let your doctor know about any cold, flu, fever, herpes breakout, or other illness you may have before your surgery.

Do NOT drink anything after midnight the night before your surgery, including water.

On the day of your surgery:

• Take any drugs your doctor prescribed with a small sip of water.
• Your doctor or nurse will tell you when to arrive at the hospital.

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 doctor 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.

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 doctor tells you exercise is safe for you.

References

International Carotid Stenting Study Investigators. Ederle J, Dobson J, Featherstone RL, Bonati LH, van der Worp HB, et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet. 2010;375:985-997.

Goldstein LB. Prevention and management of stroke. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa: W.B. Saunders; 2007:chap 58.

Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010 Jul 1;363(1):11-23. Epub 2010 May 26.

Eckstein HH, Ringleb P, Allenberg JR, et al. Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Lancet Neurol. 2008;7(10):893-902.

Adams RJ, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB, et al. Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2008;39:1647-1652.

Reviewed By

Review Date: 03/31/2011

Kevin Sheth, MD, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD. Review provided by VeriMed Healthcare Network. Also reviewed by David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine;David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.