Carotid Endarterectomy: What You Need to Know About Neck Artery Surgery

What Is Carotid Endarterectomy?

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Carotid endarterectomy (CEA) is the surgical removal of atherosclerotic plaque from inside the carotid artery, one of the main arteries in the neck. These plaques are accumulations of cholesterol, calcium, and fibrous tissue that cause narrowing of the artery over time.

The Importance of the Carotid Artery

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The carotid arteries are the two main arteries that carry oxygen-rich blood pumped by the heart to the brain. Each runs along either side of the neck and supplies different parts of the brain:

Right and Left Common Carotid Arteries:

• Arise from the aorta and travel upward through the neck
• Each divides into internal and external carotid arteries

Internal Carotid Artery:

• Supplies the front and middle portions of the brain
• Critical for vision, motor functions, and cognitive processes
• High risk of stroke in case of narrowing or blockage

External Carotid Artery:

• Supplies the face, scalp, and neck structures
• Less critical compared to the internal carotid

Atherosclerosis and Carotid Stenosis

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Atherosclerosis is a systemic disease characterized by plaque buildup on the inner surface of blood vessels. When atherosclerosis develops in the carotid arteries:

Plaque Formation:

• Cholesterol and fatty substances accumulate on the vessel wall
• Inflammatory cells migrate to the area
• Smooth muscle cells proliferate
• Calcium deposition begins
• A fibrous cap forms

Stenosis Development:

• As plaque grows, the vessel lumen (inner diameter) narrows
• Blood flow becomes restricted
• Turbulent flow develops
• Conditions favorable for clot formation are created

Complications:

• Plaque rupture and clot formation on top of it
• Clot or plaque fragments breaking off and traveling to the brain (embolism)
• Insufficient blood flow to the brain due to critical stenosis

Stroke and Carotid Disease Relationship

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Stroke is among the leading causes of death and permanent disability worldwide. Carotid disease is responsible for approximately 20 to 30 percent of ischemic strokes.

Stroke Mechanisms

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Embolic Stroke:

• Fragments breaking off from carotid plaque block brain vessels
• The most common mechanism
• Presents with sudden onset neurological deficits

Hemodynamic Stroke:

• Insufficient blood flow to the brain in severe carotid stenosis
• Usually triggered by low blood pressure or cardiac arrhythmias
• Watershed infarcts may occur

Transient Ischemic Attack (TIA)

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TIA, also known as a “mini-stroke” in common parlance:

Characteristics:

• Temporary loss of brain function
• Symptoms completely resolve within 24 hours (usually within minutes or a few hours)
• Does not leave permanent brain damage

Significance:

• May herald an impending major stroke
• Stroke risk within 90 days after TIA can be as high as 10 to 20 percent
• Requires urgent evaluation and treatment

Symptoms:

• Sudden arm or leg weakness, numbness
• Speech disturbance
• Vision loss (especially in one eye)
• Loss of balance, dizziness
• Sudden severe headache

Indications for Carotid Endarterectomy

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The decision for surgery is made based on the patient’s symptoms, degree of stenosis, and overall health status.

Symptomatic Patients

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A symptomatic patient is one who has experienced TIA or stroke due to carotid stenosis:

Definite Indications:

• Symptomatic patients with 70 to 99 percent carotid stenosis
• Recurrent TIA or stroke despite medical therapy
• Expected benefit from the procedure must outweigh surgical risk

Relative Indications:

• Symptomatic patients with 50 to 69 percent stenosis (requires individual evaluation)
• Plaque morphology (ulcerated, soft plaques) is considered

Asymptomatic Patients

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Patients with severe carotid stenosis detected but no symptoms:

Indications:

• 60 to 70 percent or greater stenosis
• Expected life expectancy must be more than 5 years
• Surgical risk must be low (complication rate below 3 percent)
• Plaque characteristics (progression, ulceration) must be evaluated

Considerations:

• Surgical benefit is more limited in asymptomatic patients
• Effectiveness of modern medical therapy has improved
• Individualized decision-making is important

Preoperative Evaluation

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Diagnostic Imaging

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Carotid Doppler Ultrasonography:

• First-line screening and follow-up method
• Evaluates degree of stenosis and plaque characteristics
• Non-invasive and radiation-free
• Repeatable and inexpensive

CT Angiography:

• Shows degree of stenosis, plaque structure, and anatomical variations
• Valuable for surgical planning
• Contrast agent and radiation exposure are disadvantages

MR Angiography:

• Radiation-free alternative
• Non-contrast techniques available
• Plaque characterization possible
• Attention needed for metal implants and claustrophobia limitations

Conventional Angiography:

• Rarely needed for diagnosis anymore
• May be used for endovascular procedure planning

Cardiac Evaluation

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A significant proportion of patients with carotid disease also have coronary artery disease:

Recommended Evaluations:

• Electrocardiography (ECG)
• Echocardiography (if needed)
• Stress testing or coronary angiography (in high-risk patients)

Risk Assessment

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High Surgical Risk Criteria:

• Advanced age (over 80 years)
• Severe heart disease
• Uncontrolled diabetes
• Chronic kidney disease
• Severe chronic obstructive pulmonary disease
• Contralateral carotid occlusion
• Previous neck surgery or radiotherapy

Surgical Technique

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Anesthesia

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General Anesthesia:

• Most commonly preferred method
• Patient is fully sedated
• Airway control is maintained
• Cerebral monitoring (EEG, oximetry) may be used

Regional (Local) Anesthesia:

• Performed with cervical block
• Patient is awake and neurological assessment can be done
• Advantage of early detection of cerebral ischemia
• Requires patient cooperation

Surgical Steps

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Preparation:

• Patient is placed supine, head turned to the opposite side
• Neck area is prepared in a sterile manner
• Cleansed with antiseptic solution

Incision and Exposure:

• Oblique incision made along the anterior border of sternocleidomastoid muscle
• Muscle and soft tissues are dissected
• Common carotid, internal and external carotid arteries are exposed
• Cranial nerves (hypoglossal, vagus, superior laryngeal) are protected

Vascular Control:

• Systemic heparin is administered (to prevent blood clotting)
• Common carotid, internal and external carotid arteries are clamped
• Cerebral blood flow is maintained via shunt or contralateral carotid

Arteriotomy and Plaque Removal:

• Carotid artery is opened longitudinally
• Atherosclerotic plaque is carefully separated from the vessel wall
• Plaque is completely removed from common carotid to internal carotid
• Inner surface of vessel is smoothed
• Residual plaque fragments are cleared

Vessel Closure:

• Primary closure or
• Closure with patch angioplasty (synthetic or autogenous vein)
• Patch use reduces restenosis risk

Restoring Blood Flow:

• Air and debris cleared before unclamping
• Clamp sequence opened carefully
• Bleeding control performed
• Hemodynamic stability ensured

Closure:

• Layers closed anatomically
• Drain may be placed (for bleeding control)
• Skin closed with sutures or staples

Shunt Use

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A shunt is a temporary tube used to maintain blood flow to the brain during surgery:

Indications:

• Contralateral carotid occlusion
• Inadequate Circle of Willis
• Signs of cerebral ischemia on shunt monitoring
• Neurological changes under local anesthesia

Advantages:

• Preserves cerebral perfusion
• May reduce stroke risk

Disadvantages:

• Technically more difficult
• Risk of vessel damage
• Risk of embolism

Alternative Treatment Options

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Carotid Artery Stenting (CAS)

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Carotid stenting is a minimally invasive alternative to carotid endarterectomy:

Procedure:

• Access through the groin artery (femoral artery) via catheter
• Stenosis area expanded with balloon
• Metal mesh stent placed
• Embolic protection devices used

Advantages:

• No neck incision required
• Anesthesia risk may be lower
• Shorter hospital stay
• May be preferred in patients with prior neck surgery

Disadvantages:

• Long-term outcomes generally less successful than endarterectomy
• Risk of embolism during procedure
• In-stent restenosis may develop
• Risk may be higher in elderly patients

Preferred Situations:

• Patients with high surgical risk
• Prior neck surgery or radiotherapy
• Anatomically high lesion location
• Contralateral laryngeal nerve palsy

Medical Therapy

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Medical therapy can be applied in addition to or instead of surgery or stenting:

Antiplatelet Therapy:

• Aspirin (75-100 mg/day) is the cornerstone
• Clopidogrel may be used as alternative or addition
• Dual antiplatelet therapy recommended in some cases

Statin Therapy:

• Lowers LDL cholesterol
• Provides plaque stabilization
• Has anti-inflammatory effects
• High-intensity statin therapy recommended

Blood Pressure Control:

• Target generally below 130/80 mmHg
• ACE inhibitors or ARBs preferred
• Excessive hypotension should be avoided

Risk Factor Modification:

• Smoking cessation (the most critical step)
• Diabetes control (HbA1c target below 7 percent)
• Weight control
• Regular physical activity
• Healthy diet (Mediterranean diet)

Complications and Risks

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Perioperative Complications

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Stroke:

• The most feared complication
• Rate is around 1 to 3 percent in experienced centers
• May be due to embolism, hypoperfusion, or intracerebral hemorrhage
• Risk is somewhat higher in symptomatic patients

Heart Attack:

• Risk exists since coronary artery disease often coexists
• Rate is around 1 to 2 percent
• Preoperative cardiac evaluation is important

Cranial Nerve Injury:

• Hypoglossal nerve (tongue movement): 5 to 8 percent
• Vagus nerve (hoarseness): 3 to 5 percent
• Marginal mandibular nerve (lip movement): 1 to 2 percent
• Most are temporary; permanent damage is rare

Neck Hematoma:

• Rate is around 5 to 7 percent
• May threaten airway in severe cases
• May require emergency surgical intervention

Wound Infection:

• Rate is below 1 percent
• Can be prevented with antibiotic prophylaxis

Late Complications

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Restenosis (Re-narrowing):

• Occurs in 5 to 10 percent within first two years
• Risk reduced with patch angioplasty
• Usually asymptomatic
• Followed with Doppler ultrasound

Pseudoaneurysm:

• Vessel wall ballooning at surgical site
• Rare; may require surgical repair

Contralateral Carotid Disease:

• Atherosclerosis is a systemic disease
• Contralateral carotid should also be monitored

Postoperative Care and Recovery

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Hospital Stay

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First 24 Hours:

• Monitoring in intensive care or close observation unit
• Neurological assessment (hourly)
• Blood pressure control (target values maintained)
• Surgical site monitoring (hematoma control)

Discharge Criteria:

• Stable neurological status
• Controlled blood pressure
• No wound site problems
• Oral intake tolerated

Recovery at Home

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First Week:

• Wound care (keep dry and clean)
• Avoid heavy lifting and straining
• Be careful with neck movements
• Pain medication use (if needed)

First Month:

• Gradual increase in activity
• Doctor approval needed for driving
• Return to work usually possible within 2 to 4 weeks
• Sutures removed within 7 to 10 days

Long Term:

• Continue medication (antiplatelet, statin)
• Risk factor control
• Regular cardiovascular follow-up
• Carotid monitoring with Doppler ultrasound

Outcomes and Success Rates

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Short-Term Outcomes

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Mortality:

• Below 1 percent in experienced centers
• May be slightly higher in symptomatic patients

Combined Stroke and Death Rate:

• 3 to 6 percent in symptomatic patients
• 1 to 3 percent in asymptomatic patients

Long-Term Outcomes

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Stroke Prevention:

• Stroke risk reduced by more than half in symptomatic 70+ percent stenosis
• Significant benefit also achieved in asymptomatic patients
• Effect persists for years

Survival:

• Life expectancy normal after successful surgery
• Coronary artery disease is the main cause of death
• Risk factor control improves survival

Clinical Study Data:

• NASCET (North American) study: 2-year stroke risk dropped to 9 percent with surgery in symptomatic 70-99 percent stenosis (26 percent with medical therapy)
• ECST (European) study: Similar results
• ACAS and ACST studies: Also demonstrated surgical benefit in asymptomatic patients

Frequently Asked Questions (FAQ)

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When Should You See a Doctor?

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Seek medical help immediately in the following situations:

1. Sudden onset neurological symptoms (weakness, numbness, speech disturbance, vision loss)
2. Suspected transient ischemic attack (TIA)
3. Pulsating swelling in the neck or hearing a bruit
4. Family history of early stroke
5. Multiple risk factors (smoking, hypertension, diabetes, high cholesterol)
6. After surgery: New neurological symptom, severe headache, neck swelling or bleeding

Book an Appointment

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To obtain information about carotid disease evaluation, diagnosis, or treatment options, you can schedule an appointment.