Carotid Artery Surgery

Carotid artery surgery is a procedure to restore proper blood  flow to the brain. The build-up of plaque in the inner layer of the  wall of an artery may lead to narrowing and irregularity. Where  the narrowing is severe, there is a risk that the vessel can block  completely if a thrombus forms in the diseased segment.

You have an artery on each side of your neck called the carotid artery.  This artery brings needed blood to your brain and face.

The blood flow in this artery can become partly or totally blocked by fatty  material called plaque. A partial blockage is called carotid artery stenosis  (narrowing). Blockage in your carotid artery can reduce the blood supply  to your brain. A stroke can occur if your brain does not get enough blood.

Thrombus

  • Sometimes the plaque may close off the artery enough to cause a stroke. 
  • Other times a blood clot may form in the artery, block the narrow part,  and stop blood from reaching the brain. This type of clot is called a thrombus.  It stays in one place. 

Embolism

  • Other times, the clot can travel and get stuck in a smaller blood vessel  in the brain.  A clot that travels like this is called an embolism.

There are 2 ways to treat a carotid artery that has plaque buildup in it. One is surgery called endarterectomy. The other is a procedure called  angioplasty with stent placement.

During carotid endarterectomy

  • You will probably receive general anesthesia. This will make you  unconscious and unable to feel pain. Some hospitals may use local anesthesia  instead. With local anesthesia, only the part of your body being worked on will  be made numb with medicine so that you will not feel pain. 
  • You will lie on your back on a padded operating table with your head turned  to one side. The side that will face up is the side your blocked carotid artery is on. 
  • Your surgeon will make an incision (a cut) on your neck over your carotid artery.  Your surgeon will put a catheter (a flexible tube) in place. Blood will flow through the  catheter around the blocked area during surgery. 
  • Then your surgeon will open your carotid artery. The surgeon will then remove  the plaque inside your artery. 
  • Your artery will be closed up with stitches after the plaque is removed.  Blood will now flow through the artery to your brain. 
  • Your heart and brain activity will be monitored closely during your surgery.

Carotid angioplasty and stenting (CAS) is a less-invasive way  to repair the blockage in your carotid artery:

  • Your surgeon will make an incision in your groin after using some  numbing medicine. You will also be given medicine to relax you. 
  • Your surgeon will insert a catheter (a flexible tube) through the incision  into an artery. The doctor will carefully guide the catheter up to your neck to  the blockage in your carotid artery. 
  • Your surgeon will use live x-ray pictures to see your artery. This kind of  x-ray is called fluoroscopy. 
  • Next your surgeon will pass a guide wire through the catheter to the blockage.  Another catheter with a very small balloon on the end will be pushed over the  guide wire and into the blockage. Then the balloon will be blown up. The balloon  then presses against the inside wall of your artery. This opens the artery and  restores proper blood flow to your brain. 
  • A stent (a wire mesh tube) may also be placed in the blocked area. The stent  is inserted at the same time as the balloon catheter. It expands when the balloon  is blown up. The stent is left in place to help keep the artery open. The surgeon  then removes the balloon.

Why the Procedure Is Performed

There are several ways your doctor may know you have narrowing or  blockage in your carotid artery. Two common ones are:

  • You may have had symptoms of a stroke or a transient ischemic attack  (TIA, also called a "mini-stroke"). Some of these symptoms are weakness,  blurred vision, confusion, or slurred speech.
  • You may not have any symptoms, but your doctor may find a problem  during a physical exam. Your doctor may hear something called a bruit  when using a stethoscope to listen to your blood flow. A bruit is an abnormal  sound in your artery.

Your doctor will need to do one or more tests to see how blocked one or  both of your carotid arteries are.  If you have had a stroke, your doctor  will consider whether treating your blocked artery is safe for you. Your doctor  will compare your risk of having another stroke if you do not have surgery  with the risk of having serious problems from the surgery itself. 

Your doctor must consider:

  • How bad the narrowing in your carotid arteries is 
  • What symptoms you have 
  • What other medical problems you may have 
  • Your age

Treatment options your doctor will discuss with you are:

  • No treatment, other than checking your carotid artery  with tests every year 
  • Medicine and diet to lower your cholesterol 
  • Tests to check your carotid artery and blood-thinning medicines to  lower your risk of stroke. Some of these medicines are aspirin, clopidogrel  (Plavix), and warfarin (Coumadin). 
  • Surgery to remove the buildup in your carotid artery Most times, patients who have carotid angioplasty and stenting to treat  severe narrowing of their carotid artery have this procedure because  carotid endarterectomy would not be safe for them.

Risks

The risks for any anesthesia are:

  • Allergic reactions to medicines 
  • Breathing problems 

The risks for any surgery are:

  •  Bleeding 
  • Infection

Risks of carotid surgery are:

  • Blood clots or bleeding in the brain 
  • Brain damage 
  • Stroke (this is rare) 
  • Heart attack 
  • Seizures (this is rare) 
  • Allergic reaction to dye (only with carotid artery angioplasty)
  • More blockage of the carotid artery over time

Before the Procedure

Your doctor will do a thorough physical exam and several medical tests. Always tell your doctor or nurse what drugs you are taking,  even drugs, supplements, or herbs you bought without a prescription.

During the 2 weeks before your surgery:

  • You may be asked to stop taking drugs that make it harder for  your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), 
    clopidogrel (Plavix), naprosyn (Aleve, Naproxen), and other drugs like these. 
  • Ask your doctor which drugs you should still take on the day of your surgery. 
  • If you smoke, you need to stop. Ask your doctor or nurse for help quitting. 
  • Always let your doctor know about any cold, flu, fever, herpes breakout,  or other illness you may have before your surgery. Do NOT drink anything after midnight the night before your surgery, including water.

On the day of your surgery

  • Take your drugs your doctor told you to take with a small sip of water. 
  • Your doctor or nurse will tell you when to arrive at the hospital.

After the Procedure

You may have a drain in your neck that goes into your incision. It will drain  fluid that builds up in the area. It will be removed within a day.

After surgery, your doctor may want you to stay in the hospital overnight so  that nurses can watch you for any signs of bleeding, stroke, or poor blood flow  to your brain. You may be able to go home the same day if your operation is  done early in the day and you are doing well.

Outlook (Prognosis)

Carotid artery surgery may help lower your chance of having a stroke.  But you will need to make lifestyle changes to help prevent plaque buildup,  blood clots, and other problems in your carotid arteries over time. You may  need to change your diet and start an exercise program, if your doctor tells  you exercise is safe for you.

Contact Stroke Center

For more information on Doylestown Hospital's Stroke Resource Center, please call Brooke Kearins, CRNP at 215-345-0105.