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A carotid endarterectomy is a surgical procedure to treat occlusion of the carotid arteries in the neck. The operation is to remove atherosclerotic plaque (accumulation of fatty deposits, cholesterol and other substances) that causes the obstruction.
The carotids are two arteries from the aorta which supply blood to a large part of the brain and all the face muscles. Sometimes narrowing occurs inside these arteries. This is called carotid stenosis and can be caused by habits or diseases the person has; for example, hypertension, smoking, hypercholesterolaemia or diabetes. Carotid stenosis increases the risk of cerebrovascular attack or stroke. A carotid endarterectomy is, therefore, the surgical procedure to resolve the carotid stenosis and reduce the risk of stroke.
When is it necessary to have a Carotid Endarterectomy?
Carotid stenosis is classified according to 2 factors: the degree of narrowing, expressed as a %, and recent cerebral symptoms (in the previous 6 months). The condition is then classified according to these criteria as symptomatic or asymptomatic stenosis.
An endarterectomy (or other carotid revascularisation procedures) should be considered in patients with symptomatic stenosis (with transient or permanent stroke) and with significant (greater than 50%)narrowing of the carotid artery.
For asymptomatic patients (stenosis discovered by chance in other imaging tests without recent neurological symptoms), the indication is not so clear. In general, the operation would be considered only for a stenosis greater than 70% after an individual assessment in each case.
How do you prepare for a Carotid Endarterectomy?
The patient does not need to make any special preparation for carotid surgery. Although it does not directly influence the procedure itself, avoiding overweight, having a heart-healthy lifestyle and not smoking can help in reducing the risk of anaesthetic and postoperative complications.
Obesity is a factor that can hinder (but not prevent) surgery and anaesthesia.
How is a Carotid Endarterectomy performed?
Carotid endarterectomy is usually performed with the patient completely asleep under a general anaesthetic. An 8-10 cm incision is made at the side of the neck to gain access to the common carotid artery and its main branches: the external carotid artery (which carries blood to the facial structures) and the internal carotid artery (which carries blood to the brain).
When the common, internal and external carotid arteries are identified and controlled, circulation through the carotid is stopped to open the artery and remove the atherosclerotic plaque causing the obstruction.
After the endarterectomy has been performed, the opening made in the artery is closed with a synthetic material structure like a "patch". This structure helps expand the area and prevent recurrence of the narrowing. Finally, the wound is closed and a drain is left to protect against post-surgical bleeding.
One of the most delicate parts of the surgery is stopping carotid circulation to perform the endarterectomy. During this period when arterial flow through the carotid artery is closed off, the blood reaches the brain through other arterial circuits compensating, through these, the function of the artery being worked on. To ensure this circulation is appropriate, medical and other tests are done before and during the operation.
If during the procedure it is detected that these compensatory circuits are not enough, an arterial shunt is performed. It consists of the placement of a small tube parallel to the area where the artery is being worked on, allowing a continuous blood flow to the brain.
Where is Carotid Endarterectomy performed?
Carotid endarterectomy surgery is always performed in an operating room, since it is major surgery and the patient must be anaesthetised and monitored throughout the intervention. The operating room has all the necessary isolation, cleaning and sterility measures to guarantee the minimum risk of post-surgical infection.
Who performs a Carotid Endarterectomy?
The operation is always performed by experienced vascular surgeons. The operation team consists of 2-3 vascular surgeons, 1-2 anaesthetists and 2 specialist surgical nurses.
How long does a Carotid Endarterectomy last?
The surgical operation generally lasts between 1½ and 2 hours. This includes preparation of the patient within the operating room, general anaesthesia and post-surgical awakening in the operating room.
What will I feel during Carotid Endarterectomy surgery?
As the surgery is almost always performed under general anaesthesia, the patient will not feel anything during the operation.
In the few cases of surgery performed under an anaesthetic block in the cervical zone, the patient may feel a certain manipulation in the area, but no pain.
After Carotid Endarterectomy
The patient is awakened in the operating room to check there are no neurological complications. The patient is then transferred to a recovery room and kept there for 6-24 hours before being transferred to the main hospital ward if there are no complications. The cervical drain is removed after arrival in the ward and the patient is discharged 24-48 hours after the surgery if everything has worked normally.
The postoperative period is not painful and there is usually no significant discomfort. The patient has to clean the surgical wound daily with topical antiseptic. There is no need to remove the stitches because the usual procedure is to suture the skin with a thread inside it.
Follow-up to assess evolution is done at outpatient clinics 1 month after the operation.
What are the possible complications of Carotid Endarterectomy?
Complications of endarterectomy are the typical ones for any vascular surgery or general anaesthetic procedure, or they may be specific to the procedure itself.
The most common general complications are infection of the surgical wound and bleeding in the form of a bruise. These, however, are not common and, even if they do appear, are rarely serious or require new operations.
The most significant specific risk of endarterectomy is the possibility of stroke during the procedure. Although this risk is very low (less than 3-6% of cases), it is implicit in the procedure. This occurs due to having to stop circulation through the carotid artery to work inside it. Also, handling a diseased artery may cause an embolism to form and pass into the intracerebral circulation.
However, the risk of a stroke occurring during the operation is generally much lower than the patient's own risk of having a stroke if the operation is not performed. In other words, the operation reduces the risk of stroke from moderate-high to very low (although, not to zero).
Other potential, but infrequent, complications are temporary injury to nerve structures near the area, such as the hypoglossal nerve (causing limited mobility of the tongue) or facial nerves (limiting movement of the face). However, a loss of sensitivity in the skin of the area being operated on is frequent. Nevertheless, these sensory disturbances are rarely severe and usually improve spontaneously within a few weeks.