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Carotid endarterectomy

Procedure description

When plaque and debris builds up in the carotid arteries (arteries in the neck which supply the brain with blood), this is known as carotid stenosis, and  small pieces can break off and travel to the brain, causing a stroke.  This stroke may be temporary (known as a transient ischemic attack, or TIA) or permanent.  It may be small or large.  A stroke or TIA may manifest itself as a focal weakness or numbness of one extremity, or one sides of the body.  It may also result in difficulty with speech, or, if the debris travels to the ophthalmic artery (which supplies the retina in the eye), it may result in focal blindness (known as amaurosis fugax). 

A carotid endarterectomy is a procedure performed to remove the plaque or debris from the artery in the neck.  Typically, the disease occurs at the bifurcation of the carotid artery (point where the common carotid artery divides into the internal carotid artery (which supplies the brain) and the external carotid artery (which supplies the scalp, face, throat and thyroid gland)).  The procedure can be done with the patient either awake or asleep.  If awake, local anesthetic and intravenous sedation is used.  If asleep, a general anesthetic is used.  The patient may be monitored using EEG (electroencephalogram) brain wave monitoring.  The patient is positioned on his/her back, with the head turned away from the side of the intended surgery.  Usually, a linear incision is made on the front border of the sternocleidomastoid muscle, and dissection performed to expose the carotid artery.  A large vein connected to the jugular vein often has to be sacrificed.  The carotid sheath, which contains the carotid artery, jugular vein (large vein draining the brain), and the vagus nerve (nerve which supplies swallowing and speech) is opened.  The surgeon may elect to give barbiturates to suppress brain activity further, in an attempt to protect the brain.  The carotid artery will be "cross clamped" with a clamp placed below and another one above the lesion (actually two are placed above the lesion, one on the internal carotid artery and the other on the external catotid artery).  Now, the surgeon will open the artery wall, clean out the artery, and close the vessel wall.  A graft of either vein from the leg, or a synthetic patch graft may or may not be used, to sew over the incised vessel, in order to expand the diameter of the vessel.  Meticulous hemostasis is achieved (the surgeon will carefully stop any bleeding points).  Closure of the wound is then performed.  A drain may be left in the wound.

Procedure Risks

Risks carotid endarterectomy can be broken down into two categories, 1) those related to the operative site, and 2) those related to the risks of anesthesia. 

Risks related to the operative site: 

Surgical Exposure: The patient is placed in a position so as to allow the surgeon good access to the neck. There is risk of non healing of the neck incision  post operatively.  There can be injury to the nerve supplying movement of the tongue (hypoglossal nerve).  If this occurs on both sides, the patient will be unable to protrude the tongue, and may require a tracheostomy (hole made through the neck into the trachea) to allow breathing.  There may be injury to the nerve assisting in swallowing, speech and voice box function (vagus nerve).  If the jugular vein is injured, this may decrease the outflow of blood from the brain, and brain swelling may occur.  Sometimes, drooping of a corner of the lip may occur.

Carotid artery injury: The surgery involves dissecting the artery supplying blood to the brain.  This artery already has plaque and debris in it.  It is possible that during the dissection down to the artery to expose it, the manipulation of the artery itself may dislodge a particle of debris into the brain, resulting in a stroke.  During the surgery on the artery, a clot or air pocket may develop in the artery, and after closing the artery, upon opening the clamps and allowing blood to flow to the brain, this debris or air pocket may travel to the brain and cause a stroke.  The lining of the vessel at the top end of the incision could develop a cleft between the intima (inner most portion of the artery) and the vessel wall, resulting in a dissection. If this occurs, the blood may not be able to travel up to the brain, and the artery could close off, possibly resulting in a stroke.  Even if everything goes well, there is a possibility of debris forming and a stroke occurring postoperatively.  Stenosis of the artery can recur, requiring additional treatment or surgery in the future.

General Risks: These include such general difficulties, such as bleeding, infection, stroke, paralysis, coma and death.  Incisions on the neck generally heal well, but could become  tender, numb,  or may heal in an unpleasant manner.   In addition, although every attempt is made to protect all areas of the body from pressure on nerves, skin and bones, injuries to these areas can occur, particularly with prolonged cases.

Risks of Anesthesia: Blood clots in the legs, heart attacks, reaction to the anesthetic, reaction to blood transfusion, if  given. 

 

Post-operative care:

There is surprisingly relatively little pain associated with craniotomies.  Your surgeon will prescribe pain medications for any pain associated with the incision. 

  1. Immediately upon discharge, contact our office and set up an appointment for staple removal if one has not already been made.
  2. Take it easy until seen by the physician.  This does not mean bed rest, but athletic activities during this period are definitely not recommended.  Please give your incision a chance to heal. 
  3. You may resume activity as your body permits, but avoid extremes.  For example, walking is fine, but avoid any strenuous running.  USE GOOD JUDGMENT  AND COMMON SENSE.  If you have a question, ask your doctor.
  4. No driving until cleared with your surgeon. 
  5. You may shower after you go home unless otherwise instructed.  Cover the incision with plastic wrap before the shower and remove it afterward.  Change dressing immediately.    You may shower without covering the incision one week after the staples are out.  Follow instructions concerning care of tape strips, stitches or staples.  Your surgeon or  nurse clinician will explain the techniques used in the closure of your incision.
  6. Sexual activities are permitted.
  7. If you notice swelling, redness or opening of the incision, or if there is any clear fluid draining from it, please contact your surgeon immediately!  If you develop a fever, stiff neck or chills, contact the office immediately.  Take your temperature at 4:00 PM daily until the clips are removed.  Call if greater than 101 degrees Fahrenheit.
  8. If you have a seizure, notify our office or come to the emergency room.
  9. If you develop any new weakness, notify our office.
  10. If you have any paralysis or weakness, post-operative care will need to be tailored to this.  If a brace for an arm of a leg has been prescribed, use it as recommended by your surgeon.
  11. If you have any questions, call our office, and for after hours emergencies, call the medical society.
  12. Take your medications prescribed on discharge, as directed.
  13. If your physician has prescribed  any medications which will "thin the blood," such as aspirin, or other non-steroidal antiinflammatory medications, take as advised by your physicians.
  14. Make sure to follow up with any other physicians involved in your care.  These may include your family physician and neurologist.

 

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