Introduction

Carotid arteries are the main arteries (a type of blood vessel) that supply blood to the brain. 

In carotid artery disease, the carotid arteries become narrowed or blocked, decreasing the blood flow to the brain (carotid artery stenosis).

Carotid endarterectomy (CEA) is a surgical procedure which is performed to reduce the risk of stroke due to carotid artery disease.^{1 2 3}

Risk factors

There are multiple risk factors for carotid artery disease (which can create the need for carotid endarterectomy), they are as follows:

• Smoking
• Alcoholism 
• Trauma to the neck
• High cholesterol 
• High blood pressure
• Family history of stroke
• Family history of high cholesterol 
• Male gender
• Old age
• Diabetes mellitus
• Atherosclerosis 
• History of heart attack
• Coronary artery disease^{3 4}

Indications

Carotid endarterectomy is indicated after a rigorous medical evaluation. The indication for CEA varies from person to person. This can include:

• An elaborate medical history
• General physical examination
• Neurological examination
• Specific tests to determine the degree of artery stenosis^{3 7}

Contraindications

CEA is contraindicated in various patients. The contraindications are:

• Patients who present acutely with a major stroke
• Patients with a history of a major stroke
• Complete internal carotid artery occlusion
• Patients who are deemed unfit by the surgeon or the anesthesiologist^{3 4}

Procedure overview

Before the surgery

A physical examination is done along with certain tests that help to visualise the brain activity and anatomy. Tests that are commonly done before the surgery are cerebral angiography, computed tomography (CT), and magnetic resonance imaging (MRI). Your healthcare provider can also include other tests depending on your condition. 

It is important to tell your healthcare provider about any known allergies that you have. 

You should also tell your healthcare provider about all your prescription medications, non-prescription medications, and supplements that you take. Certain medications are stopped a few days before the surgery, your healthcare provider will give you proper instructions regarding the same. 

The patient is advised to not consume food or water from midnight before the day of the surgery.^{3 5 7}

Diagnostic tests

Your healthcare provider can suggest the following tests if necessary. 

Laboratory studies

• Complete blood count
• Serum electrolytes
• Blood urea nitrogen
• Creatinine
• Lipid profile 
• Prothrombin time (PT)
• Activated partial thromboplastin time (aPTT)

Ultrasonography 

An ultrasound of the neck to visualise the carotid artery is done. It is called Carotid duplex ultrasonography. 

Computed tomography angiography (CTA)

This test is done on the neck. It is a three-dimensional X-ray of the neck and it provides important anatomical details of the carotid artery and the blockage which is important for carotid endarterectomy. 

Arteriography

It is done to evaluate the degree of blockage in the carotid artery.

Other tests

• ECG (Electrocardiography)
• Head MRI
• Head CT
• Carotid magnetic resonance angiography (MRA)³

Surgical procedure

Carotid endarterectomy takes about 2-3 hrs. The surgery steps for carotid endarterectomy are as follows:

• General anaesthesia or regional anaesthesia is provided according to the case 
• A surgeon creates a small incision (approximately 4 inches) in your neck to access the blocked carotid artery
• A temporary bypass may be established using a slender tube to divert blood flow around the obstruction to isolate it
• The narrowed section of the artery is then opened, and the plaque buildup is carefully removed
• The artery is repaired by stitching it closed, often using a patch to widen it and prevent future narrowing
• Once the plaque is removed and the artery is repaired, blood flow to the brain is restored through its natural pathway.⁵

Post-operative care

Generally, the patients are woken up in the operating room to ensure that their brain functions are intact. Then the patients are transferred to the recovery room and are kept under observation for 6-12 hrs, depending on the advice from the surgeon. 

A temporary drain is put in the neck to facilitate fluid loss from the surgical site. It is generally removed in 1-2 days. The surgical site is observed to check for hematomas.³

Recovery

After discharge, monitor the surgical wound up close and look out for signs of infection such as foul-smelling discharge, pus, increased pain, and fever. 

You can shower but don’t use extra hot water as it can disturb the surgical glue. Don’t rub against the surgical site either. Most patients can start normal activities in three to four weeks.^3,5

Complications

• Hypotension (reduced blood pressure)
• Hypertension (increased blood pressure)
• Cranial nerve dysfunction
• Myocardial infarction (Heart attack)
• Arrhythmia (irregular heartbeat)
• Wound hematoma (<1% chance)
• Wound infection
• Infected false aneurysm 
• Injury to hypoglossal nerve
• Injury to glossopharyngeal nerve
• Injury to the vagus nerve and its branches
• Injury to the facial nerve
• Horner syndrome
• Hyperperfusion and cerebral haemorrhage syndrome^,6

When to go to the hospital 

Remember the signs of a stroke. These are also explained by your healthcare provider.

F is for face drooping. Weakness or numbness of one side of the face.

A is for arm weakness. Or numbness.

S is for speech difficulty. Slurred speech.

T is time to call for help. Make note of the time the symptoms appear. Call the ambulance right away. ¹

Conclusion

This article delves into a surgery called Carotid Endarterectomy. Carotid arteries are the primary blood vessels supplying blood to the brain. The associated condition of carotid artery disease leads to narrowed or blocked arteries and reduced blood flow, known as carotid artery stenosis.

Carotid endarterectomy (CEA) is introduced as a surgical intervention aimed at lowering the stroke risk associated with this disease. The article covers the risk factors for carotid artery disease, including smoking, trauma, high cholesterol, and more. CEA is indicated after a thorough medical evaluation, involving a detailed medical history, physical and neurological examinations, and specific tests to assess artery stenosis. Contraindications are also outlined, including acute major stroke and complete internal carotid artery occlusion. 

The pre-surgery phase involves various diagnostic tests such as ultrasonography, computed tomography angiography, and arteriography. The surgical procedure overview includes the use of general or regional anaesthesia, a neck incision to access the blocked artery, temporary bypass if necessary, plaque removal, artery repair, and restoration of natural blood flow. 

Post-operative care details the recovery room observation, temporary drain usage, and potential complications, including hypotension, hypertension, cranial nerve dysfunction, myocardial infarction, and others. Recovery time is around three to four weeks and you should visit the hospital when you see signs of a stroke. 

FAQs

Q. Are there any dietary recommendations for patients with carotid artery disease?

1. Yes, a high with less amount of fat is recommended. Physical activity is also suggested. Your healthcare provider will recommend changes according to your disease.

Q. What are some other surgeries done for carotid artery disease?

1. Carotid angioplasty and stenting is another alternative surgery depending on your case. Transcarotid artery revascularization (TCAR) is also done in some patients. Your doctor will give you the options that are suitable for you.