Carotid endarterectomy; Carotid angioplasty and stenting; Endarterectomy

Each side of the neck has an artery called the common carotid. Each one of these arteries splits into two branches:

• The external branch brings blood to the face
• The internal branch brings oxygen-rich blood to the brain

A blockage in the internal carotid artery can reduce blood supply to the brain, causing a stroke. (See: Atherosclerosis and Stroke secondary to carotid stenosis )

Removing a blockage and blood flow to the internal carotid artery helps prevent strokes in some patients. The most common type of carotid artery surgery is a procedure called an endarterectomy.

Angioplasty with stent placement is another method. It has long been used to treat blockages in the heart (coronary) arteries, but is becoming an alternative to endarterectomy. This new technique must only be performed by an experienced surgeon.

Before surgery, your doctor will perform a complete physical exam and may order tests to look at the carotid arteries. These may include:

• Angiography or CT angiography
• Carotid duplex ultrasound
• Magnetic resonance angiography (MRA)

Other tests needed before surgery may include:

• Blood work (such as a complete blood count)
• Blood clotting tests
• Electrocardiogram (ECG)
• Heart stress test, if you have heart disease or risk factors for heart disease

Most patients will be taking aspirin or a medicine called clopidogrel (Plavix) up to the day of their surgery.

During carotid artery surgery, the health care team takes several steps to reduces the chances that a stroke will occur during the procedure. A plastic tube, called a shunt, is used to reroute blood flow to the brain. You will be hooked up to a machine that monitors your brain activity. (See: EEG ) The procedure may be done while you are awake and under local anesthetia, so that you can talk to the surgeon. However, general anesthesia is most often used, which means you will be asleep and pain-free

When deciding whether carotid artery surgery is a good idea, your doctor must consider many things. Sometimes, the doctor must decide whether surgery poses more risks to you than not doing the procedure. Your doctor will consider the following:

• How narrowed or blocked is the carotid artery?
• If you had stroke, was it mild or severe and how much did you recover from it?
• What other medical problems do you have that may make surgery more of a risk?

Your doctor may recommend carotid artery surgery if

• The carotid artery is 50-70% narrowed, in some cases
• More than 60% of the carotid artery is narrowed, even if you have no symptoms and have not had a stroke
• The carotid artery is 70-99% narrowed and you have a transient ischemic attack (TIA) or non-severe stroke

The risks for any anesthesia are:

• Reactions to medications
• Problems breathing

The risks for any surgery are:

• Bleeding
• Infection

Additional risks of carotid surgery include:

• Blood clots
• Brain damage
• Damage to certain nerves, which may cause difficulty when eating, swallowing, or talking
• Strokes during or soon after surgery
• Heart attack

Inconsistent blood pressure is relatively common after surgery and requires monitoring in an intensive care unit (ICU). However, this tends to improve within 24 hours, and should not be a cause for concern.

Carotid artery surgery usually helps prevent further brain damage and reduces the risk of stroke for many patients. However, unless you following a healthy diet and exercise (as recommended by your doctor), problems in the carotid arteries can return.

After surgery, you will usually stay in the medical facility overnight so that a health care provider can watch you for any signs of bleeding, stroke, or reduced blood flow to the brain. However, some patients may go home the same day, if the operation is done early in the day and doing well.

Meschia JF, Brott TG, Hobson RW. Diagnosis and invasive management of carotid atherosclerotic stenosis. Mayo Clin Proc. 2007 Jul;82(7):851-8.

Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet. 2008 May 10;371(9624):1612-23.