Carorid endarterectomy

What do I need treatment for?

As your vascular surgeon has explained to you, it was found that you have a medical problem related to a significant narrowing or stenosis of a carotid artery of yours. Carotid is the main artery on each side of your neck supplying this side of your brain with blood. This procedure was recommended to you because you:

1. either had warning signs of a stroke, called minor stroke or transient ischaemic attack (TIA) and it was found that this episode is related to your carotid stenosis. This puts you at high risk of a major stroke in the future. The aim of the procedure is to prevent you having this stroke
2. or you were incidentally found to have a tight carotid stenosis whilst on investigation for another problem. This condition may have not caused any symptoms yet, but its first symptom may be a major stroke. Your vascular surgeon’s assessment is that the procedure will be of value to you by preventing this stroke

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Before the operation

Before the operation is performed, certain investigations and tests need to be done. These are of two kinds:

(i) The ones used for assessment of your general health state and your suitability for the operation. These include blood tests, electrocardiography, echocardiography, chest x-ray, lung spirometry (measurement of lung function reserve), duplex ultrasonography, digital subtractive angiography or CT angiography of the carotids and cerebral arteries, and brain CT or MRI scanning

(ii) The ones done on admission usually the day before the operation, including bood tests and a new electrocardiogram

Your physician will generally require that 2 units of blood are available for you. In Greece, you need to personally liaise with the Blood Bank of your hospital in order that blood is secured for you.

Your physician will have probably asked you to discontinue for a few days (if you take) any anticoagulant, like Warfarin or Sintrom, in order to reduce the risk for bleeding, but will probably let you continue your antiplatelet drug like Clopidogrel (Iscover, Plavix) or Aspirin.

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Coming into hospital

When you are admitted, it will be quite useful to bring with you all medications you are on. Your medical history will be recorded. Later, your vascular surgeon and the anaesthetist who will put you to sleep will visit. They will explain certain aspects of the procedure and of the immediate postoperative care. You will be asked to sign a form confirming that you understand why the procedure needs to be performed, the risks of the procedure and that you agree to the surgery.

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The anaesthetic

The first part of any operation is the administration of anaesthesia. Carotid endarterectomy is usually performed under general anaesthesia. It is feasible under local-regional anaesthesia too, but this technique does not seem to be superior to general anaesthesia.

Initially, through an IV in your arm, used to provide you with fluids and medications, you will receive the anaesthetic which will put you to sleep within a few seconds. Then, a catherer will be inserted in a larger vein to give you the fluids required during and after the operation, and an “arterial line” will be used for continuous monitoring of your blood pressure. A urinary catheter may be placed in your bladder to monitor your urine output.

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The operation

An incision will be made on the side of your neck, about 8-10 cm in length. After displaying the carotid artery, the flow in it and its branches will be arrested with vascular clamps. An incision will be made along the artery to open it and the plaque which is causing the narrowing will be carefully removed. A shunt (narrow plastic tube) may be used to protect the brain from interruption of its blood supply when it is clamped.

When the inside of the artery has been cleared, it is closed with very fine stitches either directly or with the use of a small patch stitched to the artery to prevent further narrowing. This patch can be made of plastic material (usually Dacron or PTFE), but sometimes a vein from your leg may be used or a piece of animal tissue (bovine).

The wound is closed either with stitches or metal clips which will be removed after 5-7 days or with absorbable sutures not requiring removal. You may also have a small plastic drain near your wound for a short period to observe for bleeding and prevent a blood collection.

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After the operation

Following the operation you may be transferred to the Intensive Care Unit (or the High Dependency Unit) for closer observation, where you will stay for 24 hours and then you will return to your normal ward. You will wake up immediately at the end of the operation and your mobility will return to normal more or less immediately. You should not have much discomfort.

Following this sort of surgery you are unlikely to feel sick and you should be able to eat and drink again within a few hours. Some swelling in the neck is not uncommon and it settles within 7-10 days. The scar will become virtually invisible within several months.

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Going home

Most people stay in hospital for 1-3 days after carotid endarterectomy.

• Your physician will advise you to regularly go for short walks and then rest for gradual return to your normal activities
• You can have a bath and wet the surgical wound 4-5 days after the operation
• You will be able to drive when you can perform an emergency stop safely. This should be within a few weeks after the operation
• If you work, you should be able to return to work in 3-4 weeks
• You will usually be recommended to take Aspirin or Clopidogrel (Iscover, Plavix) and a statin, as you probably did before the operation

If you notice a large swelling in your neck, severe headache or any dysfunction like weakness of a limb or change in consciousness level, contact your doctor immediately.

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Are there any complications?

– As with any major operation there is a small risk of you having a cardiac complication, such as a heart attack. Chest infection may happen especially in smokers, and chest physiotherapy and/or antibiotics may be required

– A small number of people, usually between 1 and 3 in 100, who undergo a carotid endarterectomy will suffer a stroke during the operation. The medical team will take all possible precautions to avert this eventuality

– Another complication may be injury of one of the nerves near the carotid artery, which can cause difficulty in swallowing, moving the tongue, numbness in the face or tongue, or hoarseness of voice. This nerve injury is usually temporary

– The wound in the neck may occasionally bleed or a large swelling may develop. This swelling usually settles down as time goes by, but in rare cases surgery may be required to sort the problem. A much rarer complication is a false aneurysm (pseudoaneurysm) which always requires surgery

– The wound may get infected and require antibiotics. Serious infections, however, are rare

– Quite rarely after this procedure, headache on the side of the operation may occur; it is occasionally severe and accompanied by convulsions or/and focal neurological signs. These symptoms are related to the cerebral hyperperfusion syndrome, a condition caused by the increased blood flow to this side of the brain when the blood flow before the operation was very poor. This is a potentially very serious complication leading to oedema and bleeding in the brain

– Another unusual complication may be restenosis, or significant narrowing again, of the operated carotid artery, especially in people who continue to smoke; on very rare occasions, a new operation may be required

Each of these complications is rare, but overall it does mean that some patients may not survive the immediate post-operative period or be handicapped. For most patients this overall risk is around 2% – in other words 98 in every 100 patients will make a full recovery from the operation. Your medical team will take all precautions to prevent any problem and try to correct it as early as possible.

If your risk of a major complication is higher than average, usually because you suffer from a serious medical problem, your vascular surgeon will discuss it with you. It is important to remember that your vascular surgeon will recommend the operation only if he/she believes that the risk of a serious stroke without operation is greater than the risk posed by the operation itself.

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What can I do to help myself?

Although carotid endarterectomy significantly reduces the risk of future stroke by removing the dangerous atherosclerotic plaque and has very good long-term results, the procedure does not stop plaque build up. To preserve its success, you should seriously consider changes that will help avert the chances to further damage your arteries. If you don’t, you are at increased risk for a heart attack, a stroke or problems with the circulation to your feet.

These changes include:

• Quitting smoking completely
• Exercising aerobically, such as brisk walking, for 25 to 30 minutes daily
• Maintaining your ideal body weight
• Eating foods low in animal fat, cholesterol, and calories
• Taking your medication to control blood pressure, blood cholesterol and diabetes

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