Carotid endarterectomy may be performed if you have had a TIA (mini-stroke), a sudden loss of vision in one eye, or a major stroke. This is due to carotid artery disease; the narrowing of the main artery to your brain in your neck. The danger is that you may suffer another major stroke in the future.
In a small number of people a tight narrowing is discovered whilst under investigation for another problem. If this applies to you, you will still undergo the same preoperative tests, but you will be admitted to hospital electively for surgery.
The aim of carotid endarterectomy is to prevent you having a major stroke. The following information will help explain the process of a carotid endarterectomy operation.
Before treatment
Before undergoing carotid surgery, there are a number of tests that need to be done to see if you can have the surgery, and some just before surgery (preoperative tests).
Tests to determine if you are suitable for the surgery include:
Ultrasound MRA scan or a dye x-ray (digital subtraction angiogram) of the arteries
Blood tests
EKG (a heart tracking)
Echocardiogram (ultrasound scan of the heart)
Breath test
CT scan (special X-ray scan) of your brain.
You may also be doing a special MRI scan of your brain at the same time as the MRA.
These tests should be done within a few days of your symptoms. If you are fit enough, you will be offered an operation within two weeks of your symptoms appearing.
Your stay in the hospital
You should bring any medication you are currently taking with you. You should continue to take your normal medication before surgery unless otherwise stated.
You will be taken to your bed by one of the nurses who will also fill out your medical record.
You will be visited by the surgeon who will perform your surgery and also the doctor who will give you the anesthetic.
Physiotherapists and ICU or highly dependent care workers can also visit for information about your post-operative care. If you have any questions about the operation, please contact the doctors.
You will be asked to sign a form confirming that you understand why the procedure needs to be performed, the risks involved, and that you consent to the surgery.
Operation – anesthetic carotid endarterectomy
The carotid endarterectomy can be performed under either regional (local) or general anesthesia. Not all cases are suitable for regional anesthesia, and not all hospitals can offer this service. Your surgeon will advise you on the type of anesthesia that you will be offered.
For general anesthesia, a tiny needle is inserted into the back of your hand. The anesthetic will be injected through the needle and you will be asleep in seconds.
With local anesthesia, the anesthetist will give an injection into the skin of your throat to numb it. If you feel uncomfortable during the surgery, the surgeon will inject more local anesthetic. You also get some security, which is why you may not even be aware of the operation. Occasionally, it may be necessary to switch to brief general anesthesia during the operation.
A tube (catheter) can be inserted into your bladder to drain your urine.
A drop will be placed in a vein in your arm (usually your wrist) to give you some fluid during and after the surgery. Sometimes a second drop is placed in an artery at the wrist level to allow careful blood pressure monitoring during and immediately after surgery.
The operation
They have a cut that runs vertically from the angle of your jaw / earlobe to the sternum. The incision is usually 7-10 cm long.
Once the carotid artery is shown, the branches of the artery are clamped to limit blood loss during surgery. A small incision is made along the artery and the plaque or narrowing is carefully removed.
When the inside of the artery is clear, it is closed with very fine stitches. A small patch is usually sewn onto the artery to keep it from narrowing further. This patch is usually made of a material called dacron, but sometimes a vein from your leg or a piece of animal tissue (livestock) can be used.
The wound is usually closed with a prick under the skin that dissolves.
To protect the brain from an interruption in blood supply while the artery is clamped, a shunt (narrow plastic tube) is sometimes used to maintain blood flow. The shunt meanders outside the artery and merges into the artery at each end of the incision in the artery at the top and bottom.
A special listening device can be placed on your head to monitor the blood supply to your brain. This way, the surgeon can hear and see how fast your blood is flowing, which will help them make decisions during the surgery.
At the end of the operation, your surgeon can look into the artery with a special camera to check that the repair is satisfactory and that there is no blood clot.
Your surgeon may place a small plastic drain on your neck for a short time to check for bleeding and to reduce the swelling of the neck after surgery.
Recovery and aftercare
You can be taken to the High Dependency Unit up to 24 hours after your surgery so that your progress can be closely monitored.
You will wake up immediately at the end of the operation (if it was under general anesthesia). Local anesthetics are used in all cases to numb the skin so it doesn’t become uncomfortable.
After this type of surgery, you are unlikely to feel sick and you should be able to eat and drink again within a few hours. Your mobility will return to normal more or less immediately.
There is often a swelling in the neck, but it sets in within 7-10 days.
The incision on the neck is very clearly visible at first. However, this subsides and becomes practically invisible within 2-3 months.
A blood transfusion is rarely required.
Go home
Most people stay in the hospital between 2 and 4 days after the carotid endarterectomy.
If your stitches or clips need to be removed, it usually happens while you are still in the hospital. If not, your family doctor or district nurse will remove it and examine your wound.
Regular exercise such as a short walk combined with rest is recommended to gradually return to normal activity.
Driving: You can drive if you can safely perform an emergency stop and look easily over your shoulder. This is usually 2-3 weeks after surgery, but if in doubt, consult your own doctor. You should inform your insurer that you have had this surgery.
Bathing: As soon as your wound is dry after 3-4 days, you can bathe or shower as usual.
Work: If this applies to you, you should be able to return to work within 3-4 weeks of the operation. Your GP will let you know when you see him / her about your medical record.
Lifting: There are no restrictions in this area.
Medicines: You will usually be sent home with a small dose of aspirin if you have not already taken it. This makes the blood less sticky. If you’re allergic to aspirin or if it bothers your stomach, an alternative medication may be prescribed. No further changes to your medication are required.
Complications
Stroke: A small number of people, between 1 and 3 in 100 people who have a carotid endarterectomy, will have a stroke during surgery. The severity of stroke can be very mild and cause little or no disability, including severe, severe disability, and death. All possible precautions are taken to prevent this from happening.
Other Serious Complications: As with any major surgery, there is a small risk of medical complications such as heart attack, kidney failure, chest problems, or wound infections. Each of these are rare, but overall it means that some patients can experience fatal complications from their surgery. For most patients, this risk is around 2% – in other words, 98 out of 100 patients will fully recover from the operation.
If your risk of serious complications is higher, usually because you already have a serious medical problem, your surgeon will discuss this with you. It is important to remember that your surgeon will only recommend treatment if he or she thinks that the risk of stroke without surgery is much higher than the risk of the surgery itself.
Breast infections: These can occur after this type of surgery, especially in smokers, and may require antibiotic treatment and physical therapy.
Wound infection: wounds sometimes become infected and may need antibiotic treatment. Wound infections for this type of procedure are rare. The infection of the patch you are using is a very rare but serious complication.
Fluid leaks from the wound: The wound may bleed, which can lead to swelling. The swelling will usually go away on its own, but occasionally the wound may need further surgery. If you started taking tablets to thin your blood at the onset of TIA or stroke symptoms, there may be an increased risk of bleeding that may require you to return to the theater.
Nerve injuries: these are rare. Cutaneous nerves are disrupted by the incision, causing some loss of skin feel that can recover over time. Movement of the nerves near the carotid artery can cause temporary or, rarely, permanent loss of function.