Patient Information

Carotid Endarterectomy and Stenosis

September, 2005

Carotid endarterectomy is a common vascular surgical procedure which may help prevent your risk of having a stroke. Scientific evidence from recent studies supports carotid endarterectomy as an effective method of stroke prevention for people with carotid artery blockage of 70 percent or greater. It also may be beneficial for people with moderate blockage of 50 to 69 percent and recent symptoms of stroke.

The carotid arteries are the main blood vessels to your brain. Carotid arteries are located on each side of your neck and extend from your aorta in your chest to the base of your skull. These arteries supply oxygen-rich blood to your brain. Plaque forms when the internal carotid arteries become blocked by fat and cholesterol build-up. This process is called atherosclerosis. Blockage of the internal carotid arteries can reduce blood supply to the brain, and may lead to a stroke.

The plaque may cause the blood to flow abnormally, which may lead to blood clots. A clot may remain at the site of narrowing and prevent blood flow to all of the smaller arteries it supplies. Alternatively, a clot can travel and wedge into smaller vessels. This is called an embolism. If a clot or plaque blocks the blood flow to your brain, it can lead to an ischemic stroke, which may cause brain damage or death. If a clot or plaque blocks a tiny artery in the brain, it may cause a transient ischemic attack (TIA), also known as a mini-stroke.

Severe blockage is called carotid stenosis. Carotid stenosis may cause you to experience a TIA. Common temporary symptoms include difficulty speaking or understanding others, loss or blurring of vision in one eye, and loss of strength or numbness in an arm or leg. Usually these symptoms resolve in less than 10 to 20 minutes, and almost always within one hour. Even if all the symptoms resolve, it is very important that anyone experiencing these symptoms call 911 and immediately be evaluated by a qualified doctor.

Carotid stenosis is frequently asymptomatic. Your doctor may detect it through an abnormal sound called a bruit (BROO'e) when listening to your carotid arteries with a stethoscope.

Prior to determining if you are a candidate for a carotid endarterectomy, your doctor will give you a thorough examination, including your medical history. Individuals with the following medical conditions are at higher risk of having complications from this surgery:

  • Past strokes, especially large strokes without recovery
  • A heart attack within the last six months
  • Congestive heart failure
  • Uncontrolled high blood pressure
  • Unstable angina (chest pains)
  • The presence of a serious disease, such as severe heart or lung disease
  • Widespread cancer with less than a 2-year life expectancy
  • Plaque that cannot be reached through surgery
  • Severe blockage in other blood vessels that supply blood to your brain, such as the carotid artery on the other side
  • New blockage in a previous carotid endarterectomy on the same side
  • Alzheimer’s or other progressive brain disorders
  • Diabetes

Your doctor may order tests to help diagnose the extent of blockage. These tests include:

Cerebral angiography (also called vertebral angiogram, carotid angiogram)

Your arteries are not normally seen in an x-ray, so contrast dye is utilized. You are given a local anesthetic, the artery is punctured, usually in your leg, and a needle is inserted into your artery. A catheter (a long, narrow, flexible tube) is inserted through the needle and into your artery. It is then threaded through the main vessels of the abdomen and chest until it is properly placed in the arteries of the neck. This procedure is monitored by a fluoroscope (a special x-ray that projects the images on a TV monitor). The contrast dye is then injected into the neck area through the catheter, and x-ray pictures are taken. Your pulse, blood pressure, and breathing are monitored during this procedure. Risks of this procedure include:

  • An allergic reaction to the contrast dye
  • Although rare, the catheter may damage the artery or knock loose a piece of the artery wall, which can block blood flow and cause a stroke
  • A clot or bleeding at the puncture site may result in a partial blockage of blood flow to the leg

Carotid duplex (also called carotid ultrasound)

In this procedure, ultrasound is used to help detect plaque, blood clots, or other problems with blood flow in the carotid arteries. Ultrasonography is very reliable in identifying stenosis, but does not accurately assess the degree of stenosis. Because treatment is based on the degree of stenosis, treatment decisions cannot be made from ultrasonography alone.

A water-soluble gel is placed on your skin where the transducer (a handheld device that directs the high-frequency sound waves to the arteries being tested) is to be placed. The gel helps transmit the sound to your skin surface. The ultrasound is turned on and images of the carotid arteries and pulse wave forms are obtained. There are no known risks and this test is noninvasive and painless.

Additional tests may include:

Magnetic Resonance Angiography (MRA)

This is a noninvasive study which is conducted in a Magnetic Resonance Imager (MRI). The magnetic images are assembled by a computer to provide an image of the arteries in your head and neck. No contrast material is needed, but some patients may experience claustrophobia in the imager.

Magnetic Resonance Imaging (MRI)

This is a diagnostic test that produces three-dimensional images of your head using powerful magnets and computer technology.

Carotid Endarterectomy Surgery

You will be given either a general or local anesthetic before surgery. In this procedure, the neurosurgeon makes an incision in your carotid artery and removes the plaque using a dissecting tool. Removing the plaque is accomplished by widening the passageway, which helps to restore normal blood flow. Your artery will be repaired with sutures or a graft. The entire procedure usually takes about two hours. You may experience pain near the incision in your neck and some difficulty swallowing during the first few days after surgery. Most patients are able to go home after one or two days, and return to work, usually within a month. You should avoid driving and limit physical activities for a few weeks after your surgery.

There are potential complications with carotid endarterectomy surgery, just as there are with any type of surgery. There is a 1 to 3 percent risk of stroke following surgery. Another fairly rare complication is the re-blockage of the carotid artery, called restenosis. This may occur later, especially in cigarette smokers. Numbness in your face or tongue caused by temporary nerve damage is a possibility, but uncommon. This usually clears up in less than one month and most often does not require any treatment.

Carotid Angioplasty and Stenting

An alternative, new form of treatment, carotid angioplasty and stenting, shows some promise in patients who may be at too high risk to undergo surgery. Carotid stenting is a procedure in which a tiny, slender metal-mesh tube is fitted inside your carotid artery to increase the flow of blood blocked by plaques. The stent is inserted following a procedure called angioplasty, in which the doctor guides a balloon-tipped catheter into your blocked artery. The balloon is inflated and pressed against the plaque, flattening it and re-opening the artery. The stent acts as scaffolding to prevent the artery from collapsing or from closing up again after the procedure is completed.

You are awake during this procedure, and usually discharged from the hospital the following day. Most patients are able to resume normal activities when they get home.

There are several potential complications of endovascular treatment. The most serious risk from carotid stenting is an embolism, caused by a disrupted plaque particle breaking free from the site. This can block an artery in the brain, causing a stroke. These risks are minimized using small filters called embolic protection devices in conjunction with angioplasty and stenting. There is also a slight risk of stroke due to a loose piece of plaque or a blood clot blocking an artery during or right after surgery.

Hyperperfusion, or the sudden increased blood flow through a previously blocked carotid artery and into the arteries of your brain can cause a hemorrhagic stroke. Other complications include restenosis and short periods of medically treatable reduced blood pressure and heart rate.

Although surgery may reduce your risk of stroke, it does not stop plaque from building up. To prevent your arteries from hardening again, the following health tips may help:

  • Eat foods low in saturated fat, cholesterol, and calories
  • Exercise regularly, especially cardio exercises such as walking
  • Maintain your ideal body weight
  • Avoid smoking
  • Discuss taking cholesterol-reducing medications with your doctor

Before you undertake any exercise program, check with your doctor first.

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