Overview

What Is Carotid Endarterectomy?

Carotid endarterectomy or CEA, is surgery to remove plaque (plak) from the carotid arteries. These are the two large arteries on each side of your neck. They supply oxygen-rich blood to your brain. CEA is used to prevent stroke, or "brain attack," in people who have carotid artery disease. Carotid artery disease occurs when plaque builds up in the carotid arteries.

Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. Over time, plaque hardens and narrows the arteries. This limits or blocks the flow of oxygen-rich blood to your brain, which can lead to a stroke.


A carotid endarterectomy is a surgical procedure which re-tunnels the narrowed or blocked lumen (space within the blood vessel) of the carotid artery. Risk factors include smoking, high levels of blood cholesterol, diabetes mellitus, saturated animal fats and hypertension. The major causes of mortality and morbidity for carotid endarterectomy surgery are myocardial infarction, stroke, neurological deficit (transient and permanent), temporary loss of certain cranial nerve function (resulting in notable paralysis to muscles in the mouth, throat, neck and shoulders), permanent vocal cord paralysis and neck haematoma. As the surgery is performed under a general anaesthetic, patients will show usual post-operative side effects and undergo risks associated with that form of anaesthesia. We present three cases of carotid endarterectomy under general anaesthesia.

Before the treatment :

Before you have carotid surgery, there are a number of tests that need to be done to assess whether you are able to have the operation, and some immediately before the surgery (pre-operative tests).

Tests to see whether you are suitable for the operation include :

Ultrasound scan
MRA or a dye X-ray (digital subtraction angiogram) of the arteries
Blood tests
ECG (a heart tracing)
Echocardiogram (an ultrasound test of the heart)
Breathing test
CT scan (special X-ray scan) of your brain.

You may also have a special MRI scan of your brain at the same time as the MRA.

These tests should have been done within a couple of days of your symptoms. If you are fit enough, you will then be offered an operation within two weeks of your symptoms.

Your stay in hospital :

You should bring with you all the medications that you are currently taking. You should continue to take your normal medication prior to the operation unless instructed otherwise.

You will be admitted to your bed by one of the nurses who will also complete your nursing record.

You will be visited by the Surgeon who will be performing your operation, and also by the doctor who will give you the anaesthetic.

Physiotherapists and Intensive or High Dependency Care staff may also visit, to give you information about your postoperative care. If you have any remaining questions about the operation please ask the doctors.

You will be asked to sign a form confirming that you understand the why the procedure needs to be performed, the risks of the procedure and that you agree to the surgery.

The Operation :

The anaesthetic :-

Carotid endarterectomy can be performed under either regional (local) or general anaesthetic. Not all cases are suitable for regional anaesthetic and not all hospitals are able to offer this service. Your surgeon will advise you as to which method of anaesthetic you will be offered.

For a general anaesthetic, a tiny needle is placed in the back of your hand. The anaesthetic is injected through the needle and you will be asleep within a few seconds.

For local anaesthetic, the Anaesthetist will make an injection into the skin of your neck to numb it. During the operation, if you become uncomfortable, the Surgeon will inject more local anaesthetic. You will also be given some sedation, and as a result, you may not be very aware of the operation at all. Occasionally it may be necessary to convert to a short general anaesthetic during the operation.

A tube (catheter) may be inserted into your bladder to drain your urine.

A drip is placed into a vein in your arm (wrist usually) to give you some fluids during and following surgery. Sometimes, a second drip will be placed into an artery at wrist level to permit careful blood pressure monitoring during and just after the operation.

Key Points :-

Management of Risk Factors : -

Few studies have analyzed control of risk factors in a randomized, prospective manner following carotid endarterectomy.

Hypertension :

is the most powerful, prevalent, and treatable risk factor for stroke.Both systolic and diastolic blood pressure are independently related to stroke incidence. Isolated systolic hypertension, which is common in the elderly, also considerably increases risk of stroke. Reduction of elevated blood pressure significantly lowers risk of stroke. Meta-analyses of randomized trials found that an average reduction in diastolic blood pressure of 6 mm Hg produces a 42% reduction in stroke incidence.

Cigarette Smoking :

Cigarette smoking substantially increases risk of stroke with relative risk values of 1.5 to 2.2. Risk of stroke increases with the number of cigarettes smoked. Smoking cessation promptly reduces risk of stroke. Cigarette smoking has been identified as a risk factor for carotid restenosis.

Blood Lipids :

Increased serum lipid levels have not been clearly related to the overall incidence of stroke in individual population studies, and a meta-analysis of lipid-lowering trials found no benefit in terms of stroke risk reduction. However, these studies were heterogeneous in terms of agents used, degree of cholesterol reduction, and diagnosis of stroke

Alcohol Consumption :

The relationship between use of alcohol and stroke is complex. Heavy use of alcohol is associated with excessive risk of stroke whereas moderate consumption may have no effect or a slightly protective effect. The effects for ischemic and hemorrhagic stroke may differ

Postmenopausal Use of Estrogen :

The cardiovascular and cerebrovascular risk associated with postmenopausal estrogen replacement is not clear. In the Framingham study, women reporting postmenopausal use of estrogen had a more than twofold increased risk for cerebrovascular disease

Antiplatelet Therapy :

Antiplatelet therapy has been shown in individual trials and meta-analysis to reduce risk of stroke and other vascular events in patients at high risk (Grade A recommendation).

What To Expect After Carotid Endarterectomy ?

After carotid endarterectomy (CEA) surgery, you may stay in the hospital for 1 to 2 days. This allows your doctor to watch for any signs of complications. If your surgery takes place early in the day and you're doing well, you may be able to go home the same day.

Recovery :

For a few days after the surgery, your neck may hurt. It also may be hard to swallow. You may want to eat soft foods that are easy to swallow until your neck isn't as sore. Your doctor may prescribe medicine to help control any pain or discomfort. Many people are able to go back to their normal activities within about 3 weeks after having CEA. Talk to your doctor about when it's safe for you to go back to your normal routine.

What Are the Risks of Carotid Endarterectomy?

Serious complications from carotid endarterectomy (CEA) are uncommon, but they do occur. For example, there's a small risk of having a stroke during or after the surgery. This is because the procedure can dislodge blood clots, which may then block an artery. There's also a small risk of brain damage, heart attack, or death. To reduce your risk, work with a surgeon who has experience with CEA.

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