Carotid Endarterectomy

Carotid Endarterectomy (CEA) is a surgical procedure that removes the blockage in the carotid artery.  An incision is made in your neck and into the carotid artery, the plaque is removed from the artery, and then the artery is closed with stitches.  The procedure is usually done under general anesthesia, although some doctors use local anesthesia. CEA is one of the most common surgical procedures in the United States and has been performed for over 50 years.

FREQUENTLY ASKED QUESTIONS

WHAT IS CAROTID ENDARTERECTOMY ?

Two carotid arteries in the neck carry blood from the heart to the brain.  A stroke can occur when a carotid artery becomes blocked as a result of the build-up of fatty deposits (atherosclerotic plaque).  Carotid endarterectomy is a surgical procedure in which the atherosclerotic plaque is removed from the carotid artery to reduce likelihood of stroke.  Carotid endarterectomy is one of the most commonly performed blood vessel surgeries, although there is some risk that the surgery itself may actually induce stroke.  The incidence of this complication varies among surgeons and medical institutions.  Surgery is most beneficial in carefully defined patients at centers that have a low risk for surgical complication.    

WHAT ARE THE SYMPTOMS OF CAROTID ARTERIAL BLOCKAGE ?

A disturbance in either one or more of the following:

·        Sensation – numbness, weakness and/or paralysis of one side of the body or an extremity

·        Severe  headache

·        Sight – temporary blindness in one eye

·        Speech – difficulty and/or the ability to swallow

·        Strength

It is also possible to show no symptoms at all.   Other symptoms can include:

·        Mental deterioration

·        Memory loss

·        Syncopal symptoms

·        Difficulty with balance

Remember, these may also signal possible brain hemorrhage.

HOW IS CAROTID ARTERY DISEASE DIAGNOSED ?

The disease can usually be detected during your regular check-up with a physician.  The doctor will ask about symptoms of a stroke, such as if you’ve experienced numbness or muscle weakness, speech or vision difficulties or lightheadedness.  The doctor may hear a rushing sound in your carotid artery through his stethoscope.  Unfortunately, dangerous levels of disease sometimes fail to make a sound and some blockages with a low risk can make a sound, so it is possible to misdiagnose.  The doctor may choose to use various other tests to confirm or establish diagnosis, such as:

·        Doppler ultrasound imaging

This is a painless, noninvasive test in which sound waves are sent into the neck.  Echoes from the sound waves bounce off the moving blood and the tissue in the artery and can be formed into an image, which the doctor can then view.  Ultrasound is fast, risk-free and painless.  There is a very small possibility, however, of an error in an ultrasound study.    

·        Computed tomography (CT)

This test produces a series of X-rays of the head and brain.  It is not used to detect carotid artery disease but may be ordered to investigate the cause of other symptoms.

·        Arteriography and digital subtraction angiography (DSA)

Arteriography is an X-ray of the carotid artery.  It is taken by injecting a special dye into another artery in the leg or arm.  You may feel a burning sensation when the dye is injected.  DSA is also an X-ray study of the carotid artery.  It is similar to arteriography, but with DSA, less dye is used.  When you have a DSA, you mush remain still during the test.  It is important to know that these two procedures carry their own small risk of causing a stroke.

·        Magnetic Resonance Angiography (MRA)

This imaging technique is more accurate than an ultrasound and avoids the risks associated with X-rays and dye injection.  An MRA uses harmless but powerful magnetic fields to create a highly detailed image of the body’s tissues.     

WHO ARE THE BEST CANDIDATES FOR CAROTID ENDARTERECTOMY ?

The surgery is most beneficial for persons who have already had a stroke or who have experienced the warning signs of a stroke and have variant degrees of stenosis (50-70%, 70-99%).  Surgery can reduce the risk of stroke by more than 80-percent.  Recent studies have shown the selected asymptomatic patient with significant stenosis (more than 60%) can benefit from a carotid endarterectomy by reducing the risk of stroke by at least 30-percent.

The general medical and neurological condition of the patient and the experience of the surgeon have a direct effect on outcome and should, therefore, be considered in determining if a carotid endarterectomy is appropriate.

WHO IS AT RISK FOR STROKE ?

You are at the greatest risk for carotid artery narrowing if you are over the age of 65 (particularly if you smoke) and if you already have poor circulation in your legs or heart.  If you experience a lot of stress, are obese or consume excess alcohol, you are also at risk.

HOW IS CAROTID ENDARTERECTOMY PERFORMED ?

This procedure can be performed with general or local anesthesia.  The advantage of local anesthesia is that it is easy to monitor how the brain reacts to having the artery closed during repair but there are also sophisticated monitoring techniques used during general anesthesia.  The length of time required for this procedure may vary depending on the complexity of the repair required but it is usually completed within two hours.  The surgeon will make an incision in your neck over the obstruction itself and the obstruction is scraped away.  The opened area is patched with a graft made from vein from another part of your body.  The skin is then closed with sutures or clips, which can usually be removed within two weeks.

WHAT ARE THE POSSIBLE COMPLICATIONS ?

Possible complications include:

·        Blood clot (hematoma)

·        Excessive bleeding

·        Infection at the site of the incision

·        Injury to nerves in the face, vocal cord or tongue.

·        Stroke/TIA (transient ischemic attacks)

IS THE OPERATION BETTER THAN DRUG THERAPY ?

A surgical procedure seems to provide better protection against stroke than aspirin does in patent with a carotid artery at least 70-percent obstructed.  Blood thinning drugs or oral anticoagulant drugs can reduce the risk of stroke but only variably because they may also add to the trouble because of bleeding complications.  A successful carotid endarterectomy can put an end to immobilizing strokes and transient ischemic attacks.

WHAT HAPPENS RIGHT AFTER THE OPERATION ?

You must remain overnight in the Intensive Care area to watch for any complication that may possible arise.  If intravenous fluids were administered during the procedure, then blood and electrolyte tests will be performed in the ICU (intensive care unit).  The heart will be monitored by an electrocardiogram to verify that it is behaving normally.  Neurological examinations will also be given for strength evaluation of your arms and legs, hand movements, speech, sight and thought patterns. No drugs, food or water will be given orally for several hours or until the day following the procedure so that the neck area can begin to heal.  Thirst will be quenched by sucking on ice chips.  Aspirin therapy may start here and be continued indefinitely.

WHAT ABOUT RECOVERY ?
Most hospital stays for this procedure are short, lasting on average two to three days, with about two weeks recovery at home.  An outpatient exam will be done after one month to evaluate the brain function and how the wound is healing.  After this exam, a yearly exam will be scheduled.

WHAT IS THE PROBABLE OUTCOME ?

With a successful surgery, you can expect a complete healing without complications and a restoration of good blood flow to the brain.