Carotid artery disease (also called cerebrovascular disease) affects the vessels leading to the brain. Like the heart, the brain’s cells need a constant supply of oxygen-rich blood. This blood supply is delivered to the brain by the 2 large carotid arteries in the front of your neck and by 2 smaller vertebral arteries at the back of your neck. The right and left vertebral arteries come together at the base of the brain to form what is called the basilar artery. A stroke may occur when the carotid arteries become blocked and the brain does not get enough oxygen.

Carotid artery disease increases the risk of stroke in 3 ways:

• By fatty deposits called plaque severely narrowing the carotid arteries.
• By a blood clot becoming wedged in a carotid artery already narrowed by plaque.
• By plaque or a clot breaking off from the carotid arteries and blocking a smaller artery in the brain (a cerebral artery).

What is carotid endarterectomy?

Carotid endarterectomy is a type of surgery used to remove plaque from the carotid artery. It is the third most common kind of cardiovascular surgery in the United States.

During the operation, the surgeon peels the plaque away from the carotid artery. Once the plaque is removed from the carotid artery, more oxygen-rich blood can flow through the artery to the brain, reducing the risk of stroke.

Your doctor may want you to have a carotid endarterectomy if a carotid artery is narrowed 70% or more and if the narrowing may have caused

• A transient ischemic attack (TIA) or “mini stroke.” TIAs are episodes of dizziness, tingling, numbness, blurred vision, confusion, or paralysis that can last anywhere from a few minutes to a couple of hours.
• A stroke marked by loss of vision, persistent weakness, or paralysis.

Your doctor may also recommend the operation if you have not had a TIA or stroke, but your carotid arteries are narrowed 80% or more.

Patients with mild blockages of 50% or less usually do not need the operation, unless they have some of the symptoms mentioned above.

Carotid endarterectomy can prevent a future stroke and help ease the symptoms of TIAs. Studies have shown that a carotid endarterectomy works better than medicines alone in preventing a stroke in people with blockages in the carotid arteries.

But a carotid endarterectomy may not be suitable for everyone, because the procedure can be risky for patients whose overall health is poor. Patients may not be candidates for carotid endarterectomy if they have

• TIAs that are a result of narrowed blood vessels in the back of the head and not the carotid arteries.
• Severe coronary artery disease.
• High blood pressure that is not controlled by medicines.
• Severe hardening of the arteries (atherosclerosis) in many places in the body.
• Heart failure.
• Kidney failure.

What to Expect

The operation will  be scheduled at a time that is best for you and your surgeon, except in urgent cases. Be sure to tell your surgeon and cardiologist about any changes in your health including symptoms of a cold or the flu. Any infection may affect your recovery.

Also, review all medications (prescription as well as over-the-counter and supplements) with your cardiologist and surgeon.

Before surgery, you may have to have an electrocardiogram (ECG or EKG) [no link], blood tests, urine tests, and a chest x-ray to give your surgeon the latest information about your health.

If you smoke, your doctor will want you to stop at least 2 weeks before your surgery. Smoking before surgery can lead to problems with blood clotting and breathing.

The night before surgery, you will be asked to bathe to reduce the amount of germs on your skin. A medicine (anesthetic) will make you sleep during the operation. This is called “anesthesia.” Because anesthesia is safest on an empty stomach, you will be asked not to eat or drink after midnight the night before surgery. If you do eat or drink anything after midnight, it is important that you tell your anesthesiologist and surgeon.

You will  get complete instructions from your cardiologist and surgeon about the procedure, but here are some basics you can expect as a patient.

Day of Surgery

Most patients are admitted to the hospital the day before surgery or, in some cases, on the morning of surgery.

Small metal disks called electrodes will be attached to your chest. These electrodes are connected to an electrocardiogram machine, which will monitor your heart’s rhythm and electrical activity. You will receive a local anesthetic to numb the area where a plastic tube (called a line) will be inserted in an artery in your wrist. An intravenous (IV) line will be inserted in your vein. The IV line will give you the anesthesia during the operation. You will be given something to help you relax (a mild tranquilizer) before you are taken into the operating room.

After you are completely asleep, a tube will be inserted down your windpipe and connected to a machine called a respirator, which will take over your breathing. Another tube will be inserted through your nose and down your throat, into your stomach. This tube will stop liquid and air from collecting in your stomach, so you will not feel sick and bloated when you wake up. A thin tube called a catheter will be inserted into your bladder to collect any urine produced during the operation.

The surgeon will make a cut (called an incision) in the neck to get to the carotid artery. The surgeon places a tube (called a shunt) into the artery above and below the blockage. The shunt lets blood flow around the blockage to nourish the brain. The surgeon then peels the plaque from the inside of the carotid artery. When all of the plaque is removed, the shunt is removed, and the incision in the artery is closed by stitching a patch of fabric (Dacron) or vein into the incision.

A carotid endarterectomy can also be done by a technique that does not require blood flow to be rerouted. In this procedure, the surgeon stops the blood flow just long enough to peel the blockage away from the artery.

The surgery takes about 1 to 2 hours.

Recovery Time

You can expect to stay in the hospital for about 1 to 3 days, including 1 day in the Intensive Care Unit (ICU). During that time in the hospital, you will need to lie flat and not move your head too much. You may find that your neck aches, and this may last for up to 2 weeks. Try to avoid physically demanding activities for about 1 week. It may take as long as 2 weeks before you are totally healed.

Life After Carotid Endarterectomy

After a carotid endarterectomy, you should limit the fat and cholesterol in your diet. Your doctor may want you to start an exercise program. Other lifestyle changes include quitting smoking, limiting how much alcohol you drink, and controlling your blood pressure and cholesterol levels.