Carotid Surgery

What is a carotid endarterectomy?
A carotid endarterectomy (or “CEA”) is a surgical procedure in which a surgeon opens up one of the arteries in the side of the neck which supplies blood to the brain to remove obstructing plaque.

What causes this plaque to form?
The blockage is usually the result of atherosclerosis, a degenerative and inflammatory condition which can affect arteries anywhere in the body. Genetics play a role. Having abnormal cholesterol levels and / or high blood pressure can play a role. Smoking most definitely speeds up the development of these blockages.

How is the condition diagnosed?
A doctor or other health care provider may hear turbulence in the patient’s neck when listening with a stethoscope. This is called a “bruit” and can suggest an underlying blockage warranting further study. However, the absence of a bruit does not rule out the presence of a significant blockage. A more accurate test is a duplex ultrasound exam. This test visualizes the arteries in the neck as well as the direction and speed of blood flow, which can be used to estimate, fairly accurately, the degree of blockage (ie: 50 – 70%) A magnetic resonance angiogram (MRA) test will also show these vessels and help estimate the degree of blockage. A CT angiogram is a similar newer test used in this manner. The “gold standard” test, which may only be necessary in selected patients, is called a cerebral angiogram. Similar to a cardiac catheterization, this invasive study involves snaking a thin catheter from the groin up to the neck under X - ray. Iodine - containing fluid is injected into the vessels revealing in clear detail the anatomy.

Who should get such tests?
Many physicians will order a carotid duplex exam if they hear a bruit, if a patient has suffered a stroke or mini - stroke, or even if they are simply at high risk for blockage given the patients other medical conditions and age. Sometimes, doctors will see bits of cholesterol plaque flowing through tiny vessels in the back of the eye when they look in with an ophthalmoscope, prompting further study.

Why do we worry about carotid blockages?
These plaques place patients at risk for disabling stroke. These strokes can occur when bits of plaque or adherent platelets break off and travel up into the brain where they lodge and block flow. Additionally, the narrowed area can abruptly shut down when a large plug forms or when the plaque itself cracks and fills with blood, expanding rapidly to completely occlude the carotid artery.

When is surgery necessary?
Physicians generally recommend CEA when the blockage reaches the 70% range. This is particularly the case when the patient has had symptoms from the blockage such as mini – stroke (transient ischemic attack or “TIA”), or overt stroke. Patient age, other medical conditions, and the condition of the other carotid artery also factor into this decision-making.

Are there other mean than surgery to treat these blockages?
Yes. Some physicians may recommend using medicines such as blood thinners and statins to treat carotid blockages, particularly for folks who may not be able to tolerate surgery. Angioplasty with placement of carotid stents may also be an option for selected patients. Currently, the scientific data suggests that carotid stenting has a somewhat higher risk of causing a stroke during the procedure than conventional surgery, and should therefore be limited to patients with unusual circumstances such as recurring blockage after surgery (rare), or the inability to undergo anesthesia for conventional CEA surgery.

How is CEA performed?
Patients usually come into the hospital on the same day as the operation. Many physicians require EEG (brain wave) monitoring during surgery, so special wires are taped to the patient’s head before going to sleep. The operation takes about 60 – 90 minutes to perform, and the patient usually spends 24 to 72 hours in the hospital after surgery.

Can both sides be operated on concomitantly?
No. We stage these procedures about 6 weeks apart if both sides require CEA.

How big is the scar?
Patients can expect a 3 to 4 inch incision along the side of the neck paralleling the strap muscle.

What are the risks of surgery?
Any procedure on the carotid arteries carries a risk of stroke. Fortunately, this risk is small, about 0.5 – 1.5 %. Other risks include bleeding and injury to nerves in the area called cranial nerves. Such nerve injury is very rare, but can produce problems like hoarseness, swallowing difficulty, or tongue movement problems.

What is the benefit of CEA?
We perform CEA to substantially reduce the risk of disabling stroke. Studies have shown that CEA is very effective in this manner.