Carotid Endarterectomy: Surgery for Blocked Neck Arteries

What Is Carotid Endarterectomy?

Carotid endarterectomy (CEA) is a surgical procedure that removes fatty plaque deposits from the carotid artery in the neck to restore normal blood flow to the brain and prevent stroke. The surgery involves opening the artery, carefully removing the atherosclerotic plaque, and closing the artery with sutures or a patch.

The carotid arteries are the major blood vessels on each side of your neck that supply blood to your brain. When these arteries become narrowed by a buildup of cholesterol, fat, and other substances (a condition called atherosclerosis or carotid artery stenosis), it restricts blood flow and can lead to stroke. Small pieces of plaque can also break off and travel to the brain, blocking smaller blood vessels and causing a stroke or transient ischemic attack (TIA, also called a "mini-stroke").

Carotid endarterectomy has been performed since the 1950s and remains one of the most studied and effective surgical procedures for stroke prevention. Landmark clinical trials, including the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST), have demonstrated its significant benefits for appropriate patients.

The procedure is typically recommended for patients with significant carotid artery narrowing, particularly those who have experienced symptoms such as a TIA or minor stroke. For symptomatic patients with stenosis greater than 50%, surgery has been shown to substantially reduce the risk of future stroke compared to medical treatment alone.

Who needs carotid endarterectomy?

Carotid endarterectomy is not appropriate for everyone with carotid artery disease. Your doctor will consider several factors when determining if surgery is right for you, including the degree of artery narrowing, whether you have had symptoms, your overall health, and the surgical team's experience and outcomes.

According to current guidelines from the European Society for Vascular Surgery (ESVS) and American Heart Association (AHA), surgery is generally recommended for:

• Symptomatic patients (those who have had a TIA or stroke) with carotid stenosis of 50-99%
• Asymptomatic patients (those without symptoms) with stenosis of 60-99%, when the surgical risk is low and life expectancy is reasonable
• Patients whose stenosis is caused by atherosclerosis (fatty plaque buildup)

Surgery is typically not recommended for patients with complete blockage (100% occlusion) of the carotid artery, as the procedure cannot restore blood flow through a completely blocked vessel. In these cases, the body often develops alternative blood supply routes to the brain.

How Do You Prepare for Carotid Surgery?

Preparation for carotid endarterectomy includes stopping smoking and alcohol, fasting before surgery, washing with antibacterial soap, and having catheters placed. Your surgical team will provide specific instructions about medications, what to expect, and any tests needed before the procedure.

Proper preparation is essential for a successful surgery and smooth recovery. The specific instructions you receive may vary depending on your hospital and surgical team, but there are several common elements to most pre-operative preparations.

Before your surgery, you will typically meet with your surgeon and anesthesiologist to discuss the procedure, anesthesia options, and any questions you may have. This is also an opportunity to discuss your medical history, current medications, and any allergies. Your surgical team will explain what to expect before, during, and after the operation.

Quit smoking and limit alcohol

If you smoke, quitting before surgery is one of the most important things you can do to improve your outcome. Smoking significantly increases the risk of surgical complications, slows wound healing, and makes recovery more difficult. Most surgeons recommend stopping smoking at least 4 weeks before surgery, though stopping even a few days beforehand provides some benefit.

Similarly, reducing or eliminating alcohol consumption before and after surgery helps minimize complications and supports faster healing. Alcohol can interfere with anesthesia and pain medications, increase bleeding risk, and impair your immune system's ability to fight infection.

Fasting before surgery

You will need to fast (not eat or drink) for a specified period before your surgery, typically starting at midnight the night before. This is important for anesthesia safety, as having food or liquid in your stomach during anesthesia can cause serious complications. Your surgical team will give you specific instructions about when to stop eating and drinking.

Antibacterial washing

To reduce the risk of surgical site infection, you will typically be asked to wash with a special antibacterial soap solution. This is usually done twice: once on the evening before surgery and once on the morning of surgery. The soap helps eliminate bacteria on your skin that could potentially cause infection.

Catheters and IV access

Before the surgery begins, the medical team will place several lines and catheters:

• A urinary catheter (a thin, flexible tube inserted into your bladder) to drain urine during and after the procedure
• An intravenous (IV) line, usually placed in your arm, to deliver fluids, medications, and anesthesia during surgery
• Additional monitoring equipment may be attached to track your heart rhythm, blood pressure, and oxygen levels throughout the procedure

Medication adjustments

Your doctor will review all your current medications and provide specific guidance about which ones to continue, stop, or adjust before surgery. This is particularly important for:

• Blood thinners (anticoagulants like warfarin, or antiplatelet drugs like clopidogrel) may need to be stopped or adjusted to reduce bleeding risk
• Diabetes medications may need dose adjustments due to fasting
• Blood pressure medications are often continued but may be adjusted
• Aspirin is typically continued as it helps prevent blood clots

How Is Carotid Endarterectomy Performed?

During carotid endarterectomy, the surgeon makes a 5-10 cm incision in the neck, opens the carotid artery, removes the plaque causing the blockage, and closes the artery with sutures or a patch. The surgery takes approximately 1.5 to 2 hours and can be performed under local or general anesthesia.

Understanding what happens during surgery can help reduce anxiety and help you prepare for the procedure. While the specific techniques may vary slightly between surgeons and hospitals, the fundamental steps of carotid endarterectomy are well established.

Anesthesia options

Carotid endarterectomy can be performed under either local anesthesia (you are awake but the neck area is numbed) or general anesthesia (you are completely asleep). Both approaches are safe and effective, and your surgical team will discuss which option is most appropriate for your situation.

With local anesthesia, you remain awake and can communicate with the surgical team throughout the procedure. This allows the surgeon to monitor your brain function in real-time by asking you to perform simple tasks (such as squeezing a hand or speaking). If any problems are detected, the surgeon can take immediate action.

With general anesthesia, you are completely unconscious and feel nothing during the surgery. Special monitoring techniques may be used to assess brain function during the procedure.

The surgical procedure step by step

The surgery follows these general steps:

1. Positioning: You lie on your back on the operating table with your head turned slightly to expose the side of the neck where the stenosis is located.
2. Incision: The surgeon makes an incision approximately 5-10 centimeters long on the side of the neck, along the front edge of the sternocleidomastoid muscle.
3. Exposure: The carotid artery is carefully exposed by moving aside surrounding tissues and muscles.
4. Clamping: The artery is clamped above and below the plaque to temporarily stop blood flow. In some cases, a temporary shunt (a small tube) may be inserted to maintain blood flow to the brain during the procedure.
5. Arteriotomy: The surgeon makes a lengthwise incision in the artery to open it and expose the plaque.
6. Plaque removal: The atherosclerotic plaque is carefully peeled away from the artery wall. The surgeon removes all the material causing the blockage and ensures the inner surface of the artery is smooth.
7. Closure: The artery is closed with fine sutures. Often, a patch (made from a vein taken from the leg or synthetic material) is sewn into the artery to widen it and reduce the risk of re-narrowing.
8. Wound closure: The surgical wound is closed in layers. Stitches used in the skin are typically the type that dissolve on their own.

The entire procedure typically takes between 1.5 and 2 hours, though this can vary depending on the complexity of your case and the surgical technique used.

What Happens After Carotid Endarterectomy?

After carotid endarterectomy, you may experience neck pain, hoarseness, and difficulty swallowing temporarily. Most patients stay in hospital 2-3 days, can eat normally the next day, and return to regular activities within 2-4 weeks. A follow-up ultrasound at 4-6 weeks confirms proper healing.

Recovery from carotid endarterectomy is generally straightforward for most patients, though individual experiences can vary. Understanding what to expect in the hours, days, and weeks following surgery can help you prepare and know when to seek medical attention.

Immediately after surgery

After the procedure, you will be taken to a recovery area where medical staff will closely monitor your vital signs, including blood pressure, heart rate, and neurological function. It is common to experience some discomfort, including:

• Neck pain and tenderness around the surgical site
• Nausea, which can be treated with medication
• Hoarseness or voice changes, due to temporary nerve irritation
• Difficulty swallowing, especially during the first day after surgery

Pain medication and anti-nausea medication will be provided as needed. You will have stitches at the incision site on your neck; these are typically the dissolvable type that do not need to be removed.

Hospital stay

Most patients stay in the hospital for 2 to 3 days after carotid endarterectomy. During this time, the medical team will monitor you for any complications, manage your pain, and help you begin to mobilize. By the day after surgery, you will typically be able to:

• Eat and drink normally
• Get out of bed and walk around
• Have your urinary catheter removed

Going home and recovery at home

Once you are discharged from the hospital, recovery continues at home. Most people can return to light activities within a few days and resume normal activities within 2 to 4 weeks. Full recovery typically takes 4 to 6 weeks.

During your recovery at home, you should:

• Keep the incision clean and dry
• Avoid strenuous activities and heavy lifting for several weeks
• Follow any driving restrictions given by your doctor
• Take prescribed medications as directed
• Attend all follow-up appointments

Follow-up care

Approximately 4 to 6 weeks after surgery, you will have a follow-up appointment that typically includes an ultrasound examination of your carotid artery. This imaging test allows your doctor to verify that the artery has healed properly and that there are no new blockages forming.

You will also see your surgeon for a clinical examination and to discuss your recovery. Long-term follow-up may include periodic ultrasound examinations to monitor the artery over time.

What Are the Risks and Complications?

Complications from carotid endarterectomy are uncommon but can include stroke (2-3% risk), heart attack, wound infection, nerve damage causing hoarseness or numbness, bleeding, and re-narrowing of the artery. The benefits of preventing future stroke typically outweigh these risks for appropriate candidates.

Like any surgical procedure, carotid endarterectomy carries some risks. However, when performed by experienced surgeons at high-volume centers, the complication rate is low and the benefits of stroke prevention typically outweigh the risks for appropriate patients.

The combined risk of stroke or death from carotid endarterectomy is approximately 2-3% for symptomatic patients and 1-2% for asymptomatic patients at experienced centers. This risk must be weighed against the significantly higher risk of stroke if carotid stenosis is left untreated.

Possible complications include:

• Stroke: The main risk of surgery. A stroke can occur during or shortly after the procedure if a blood clot or piece of plaque travels to the brain.
• Heart attack: Patients with carotid artery disease often have coronary artery disease as well, which increases heart attack risk during surgery.
• Wound infection: Signs include redness, swelling, warmth, pain, discharge, or fever. Most infections are easily treated with antibiotics.
• Nerve damage: Temporary or rarely permanent damage to nerves near the carotid artery can cause hoarseness, difficulty swallowing, facial numbness, or tongue weakness. Most nerve problems resolve within weeks to months.
• Bleeding: Significant bleeding is uncommon but may require return to the operating room.
• Re-stenosis: The artery can narrow again over time, though this is less common when a patch is used during closure.

Factors affecting complication risk

Your individual risk of complications depends on several factors, including:

• Your overall health and presence of other medical conditions
• Whether you have had symptoms (TIA or stroke)
• The degree and characteristics of your carotid stenosis
• The experience and outcomes of your surgical team

Choosing a surgeon and hospital with high volumes of carotid endarterectomy procedures and documented low complication rates is one of the most important factors in achieving good outcomes.

What Results Can You Expect?

Carotid endarterectomy provides excellent long-term results, reducing stroke risk by 50-65% in symptomatic patients and maintaining artery patency in over 90% of cases. The benefits are greatest when surgery is performed soon after symptoms occur and at experienced surgical centers.

Carotid endarterectomy has been extensively studied in large clinical trials and has proven to be highly effective at preventing stroke in appropriate patients. Understanding the expected outcomes can help you make an informed decision about treatment.

Stroke prevention effectiveness

The landmark NASCET study demonstrated that for symptomatic patients with severe carotid stenosis (70-99%), surgery reduced the 2-year risk of ipsilateral stroke from 26% to 9% - an absolute risk reduction of 17%. Even for moderate stenosis (50-69%), surgery provided significant benefit.

For patients who have experienced a TIA or minor stroke, carotid endarterectomy can reduce the 5-year stroke risk from approximately 22% to 11%. The benefits are greatest when surgery is performed within 2 weeks of symptoms, highlighting the importance of timely surgical evaluation.

Long-term durability

The results of carotid endarterectomy are durable, with over 90% of arteries remaining open (patent) in the long term. Re-narrowing (restenosis) does occur in some patients but is less common when a patch is used during arterial closure. Most cases of restenosis do not cause symptoms and can be monitored with periodic ultrasound examinations.

Quality of life

Most patients return to their normal activities and quality of life within weeks of surgery. The peace of mind from significantly reducing stroke risk is an important benefit that many patients value highly.

Taking an Active Role in Your Care

You have the right to understand your treatment options, ask questions, and participate in decisions about your care. Seeking a second opinion, understanding risks and benefits, and preparing questions for your medical team are all appropriate and encouraged.

Making decisions about surgery can feel overwhelming, but remember that you are an important partner in your healthcare. Understanding your condition, treatment options, and what to expect empowers you to make informed decisions and participate actively in your care.

Questions to ask your doctor

Consider asking your healthcare team the following questions:

• What is the degree of narrowing in my carotid artery?
• Am I a good candidate for surgery? What are my alternatives?
• What is your experience performing this procedure?
• What are the specific risks and benefits for someone in my situation?
• What type of anesthesia do you recommend and why?
• What should I expect during recovery?
• What medications will I need to take after surgery?

Understanding the information you receive

It is important that you understand the information provided by your healthcare team. If something is unclear, ask for it to be explained in different terms. You may also request written information to review at home or bring a family member or friend to appointments to help remember what was discussed.

If you do not speak the language fluently or have hearing difficulties, you have the right to assistance such as interpreter services.