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
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.
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.
related to the operative site:
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.
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.
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
of Anesthesia: Blood clots in the legs, heart attacks,
reaction to the anesthetic, reaction to blood transfusion,
is surprisingly relatively little pain associated with craniotomies.
Your surgeon will prescribe pain medications for any pain
associated with the incision.
upon discharge, contact our office and set up an appointment
for staple removal if one has not already been made.
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.
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.
driving until cleared with your surgeon.
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.
activities are permitted.
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.
you have a seizure, notify our office or come to the emergency
you develop any new weakness, notify our office.
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.
you have any questions, call our office, and for after
hours emergencies, call the medical society.
your medications prescribed on discharge, as directed.
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.
sure to follow up with any other physicians involved in
your care. These may include your family physician