Introduction
The carotid arteries supply blood to the front of the brain, and travel upwards on both sides of the neck. When fatty deposits build up inside these arteries (or 'plaque'), narrowing or ‘stenosis’ occurs, thus restricting blood flow to the brain. In some cases, the plaque is unstable, and portions can break off to travel downstream, block off arteries in the brain, and cause strokes. Carotid endarterectomy (CEA) is a procedure to remove this plaque from the arterial wall and restore proper blood flow to the brain and reduce the risks of further strokes.
An alternative approach is carotid artery stenting (CAS), which is an endovascular procedure. A stent is a metal sleeve or cylindrical mesh that is inserted on the inside of the artery to keep it widely opened. During stent placement, a balloon is inserted to expand the narrowing within the artery (‘angioplasty’). Stenting is an alternative to endarterectomy when endarterectomy is either not possible or where the risks are deemed to be too great.
Indications
Both procedures are treatments or preventative treatments for…
- Stroke (from ruptured plaque).
- Mini-stroke or Transient ischaemic attack (TIA).
- Blockage of the carotid artery with symptoms present during changes in posture.
- Severe blockage of the carotid artery (without symptoms present).
Preoperative Instructions
Before either of these procedures, you should…
- Have no food or drink from midnight the night before the procedure. Medications are allowable with very small sips of water.
- Let our office know if you take blood thinners - you may need to stop or change these ahead of the procedure. Consult your surgeon about blood thinner medications. CEA can be performed with aspirin or clopidogrel alone. CAS should be performed with two anti-platelet medications (e.g. aspirin and clopidogrel).
- Dental treatment (within three weeks) or any other form of surgery (within three months) of the planned procedure should be avoided.
- If there are any symptoms of infection, e.g. a cold or flu, before surgery, or if you are receiving treatment for an infection, you may need to reschedule your procedure. Please inform our office as soon as possible.
Procedures
Carotid endarterectomy
The procedure can be carried out either under a general or local anaesthesia. An incision is made to the front of the neck. The carotid artery is identified, and is temporarily clamped so that the plaque is removed from the internal artery wall. The artery wall is then repaired either sutures. Sometimes, a shunt and a graft using an artificial 'patch' is necessary for the repair.
Carotid artery stenting / carotid angioplasty
The patient may undergo this procedure, with sedation and local anaesthetic applied to the incision site in the groin, or with general anaesthesia. The procedure involves a small incision in the groin to allow a thin tube (a 'catheter') to be advanced through the blood vessels to the affected carotid artery. When it has reached the site, a small medical 'balloon' is inflated to widen the artery and a 'stent' (a small metal mesh tube) may be permanently fitted in the artery to keep it open. Once the procedure is complete, the catheter is withdrawn from the incision in the groin, which is then closed.
In unstable plaques that cause acute strokes with blockage in a brain artery, the blood clot is removed from the brain artery (see endovascular clot retrieval) together with treating the narrowing in the carotid artery from the plaque. A carotid angioplasty and / or stent is performed at the same time.
Postoperative Instructions
Carotid endarterectomy
Patients will be admitted for a short (1-2 day) hospital stay, which may include intensive care for monitoring. A sore throat and minor difficulty swallowing are normal after surgery to the neck, and so bland, soft foods may be easier to eat. For 7-14 days after surgery you should avoid driving, heavy lifting and other strenuous physical activity, including exercise. Most patients are able to return to work and normal activities within 2-4 weeks.
Carotid artery stenting/carotid angioplasty
Most patients are able to return home within 24 hours of the procedure. Heavy lifting and other strenuous physical activity should be avoided for at least 1 week afterwards.
With either procedure you should seek immediate medical assistance if…
- You have difficulty walking.
- You have difficulty speaking.
- You have numbness on one side of the body.
- You have a return of any previous symptoms.
Risks
Risks with both procedures include…
- General risks associated with surgery and anesthesia.
- Stroke/mini stroke/transient ischaemic attack.
- Restenosis (where the arteries narrow again).
- Nerve damage (for CEA), such as difficulty moving tongue.
- Heart attack.