Carotid Endarterectomy

What is a carotid endarterectomy?

Carotid endarterectomy (CEA) is surgery to treat 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.

During a carotid endarterectomy, your healthcare provider will surgically remove plaque that has built up inside the carotid artery. Your healthcare provider will make a cut (incision) on the side of the neck over the affected carotid artery. The artery is opened, and the plaque is removed. Your healthcare provider will stitch the artery back together. This restores 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 is also called "hardening of the arteries." It can affect arteries throughout the body. Carotid artery disease is like coronary artery disease. In coronary artery disease, blockages form 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 work correctly. 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 happen. A mini-stroke (transient ischemic attack, or TIA) is stroke-like symptoms that last only a few minutes to a few hours. A TIA may be the first sign of carotid artery disease.

You may not have symptoms if you have carotid artery disease. Plaque buildup may not be blocking enough blood flow to cause symptoms. An artery that is blocked only halfway or less often does not cause any symptoms.

Your healthcare provider may have other reasons to advise a carotid endarterectomy.

What are the risks of a carotid endarterectomy?

Some possible complications of carotid endarterectomy include:

• Stroke or TIA

• Heart attack

• Pooling of blood into tissue around the incision site causing swelling

• Nerve problems with certain functions of the eyes, nose, tongue, or ears

• Bleeding into the brain (intracerebral hemorrhage)

• Seizures (uncommon)

• Repeated blockage of the carotid artery, or a new blockage that develops in the artery on the other side of your neck

• Bleeding at the incision site in the neck

• Infection

• High blood pressure

• Irregular heartbeat

• Blocked airway from swelling or from bleeding in the neck

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

There may be other risks based on your condition. Discuss any concerns with your healthcare provider before the procedure.

How do I get ready for a carotid endarterectomy?

• Your healthcare provider 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 healthcare provider 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 healthcare provider if you are sensitive to or are allergic to any medicines, iodine, latex, tape, contrast dye, or anesthesia.

• Tell your healthcare provider about all the prescription and over-the-counter medicines and herbal supplements that you are taking.

• Tell your healthcare provider if you have a history of bleeding disorders. Also tell your healthcare provider 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 healthcare provider.

• Follow any directions you are given for not eating or drinking before surgery.

• Your healthcare provider may request a blood test before the procedure to find out how long it takes your blood to clot.

• You may get medicine (sedative) before the procedure to help you relax.

• Tell your healthcare provider if you have a pacemaker.

• If you smoke, stop smoking as soon as possible before the procedure. This may help you recover faster. It may also improve your overall health status. Smoking raises the risk for blood clots.

• Based on your condition, your healthcare provider may give you other directions for getting ready.

What happens during a carotid endarterectomy?

Carotid endarterectomy requires a stay in the hospital. Procedures may vary based on your condition and your healthcare provider'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 IV (intravenous) 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 into your neck, opposite the surgery site, to monitor your heart. Other sites for the catheter include under the collarbone area and the groin.

5. If there is too much hair at the surgical site, the healthcare team may shave it off.

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

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

8. The anesthesiologist will 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 healthcare provider 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 healthcare provider will give you 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, the healthcare provider will put a breathing tube into your throat and into your windpipe to provide air to your lungs. You will be connected to a ventilator. This machine will breathe for you during the surgery.

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

14. The healthcare team will clean the skin over the surgery site with an antiseptic solution.

15. The healthcare provider will make a cut (incision) down the side of the neck over the diseased artery. Once the artery is exposed, the healthcare provider will make a cut into the artery.

16. The healthcare provider may use a device called a shunt to divert blood flow around the surgery area. It will keep blood flowing to the brain. A shunt is a small tube that is put into the carotid artery to send blood flow around the area being operated on.

17. With the blood flow diverted, the healthcare provider will remove the plaque from the artery.

18. The healthcare provider will then remove the shunt and carefully close the artery. The incision in the neck will be stitched together.

19. A small tube (drain) may be placed in your neck. It will 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 healthcare provider will wake you up in the operating room to be sure you can respond to questions.

22. A sterile bandage or dressing will be put on the surgery site.

What happens after a carotid endarterectomy?

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

• What results to expect and what they mean

• The risks and benefits of the test or procedure

• What the possible side effects or complications are

• When and where you are to have the test or procedure

• Who will do the test or procedure and what that person’s qualifications are

• What would happen if you did not have the test or procedure

• Any alternative tests or procedures to think about

• When and how you will get the results

• Who to call after the test or procedure if you have questions or problems

• How much you will have to pay for the test or procedure