What is carotid endarterectomy (CEA)?
Surgery of the carotid artery for prevention of stroke is called “carotid endarterectomy”. This is the most intensely studied surgical procedure in the history of modern medicine and there are numerous large-scale studies reported in respected medical journals. There is universal acknowledgement that CEA prevents strokes in carefully selected patients. The operation can be done under general anesthetic or local anesthetic. However, most patients prefer having the procedure done while asleep. An oblique incision is made along the neck and the carotid artery is carefully exposed.
The artery is clamped above and below the plaque to allow it to be opened without bleeding. A temporary shunt is inserted to restore blood flow. The plaque causing the blockage is removed (“endarterectomized”). A vein from the ankle or the groin is then harvested and sewn onto the artery as a patch to complete the repair. Occasionally, a synthetic patch or no patch is used. The shunt is removed and the clamps are released to restore blood flow to the brain. A small drain may be left near the artery and the incision is closed. You will be kept in the post-operative recovery room for a few hours of observation and then transferred to your room. The drain is removed the day after surgery. Most patients feel well enough to go home the following morning but usually are discharged on post-operative day two.
What are the potential complications of carotid endarterectomy?
There is a 4% chance that you may have a stroke or that you may not survive the operation. This risk is lower (2%) if you have never experienced a stroke or mini stroke prior to the surgery. The risk of an injury to one of the nerves in the neck is about 5%. This can result in difficulty swallowing, speaking, or even breathing but the majority of these will recover over time. Some patients may experience bothersome numbness or tingling around the incision or the earlobe but again this should resolve over a few months. There is a 5% chance of developing a hematoma (bleeding) in the neck. Sometimes this requires re-operation to relieve the pressure and to repair the source of bleeding. This complication is more frequently seen in patients taking aspirin or Plavix. Infections occur in <1% of cases. Nevertheless, the vast majority of patients have an uncomplicated post-operative course despite these quoted risks.
How long will it take for me to recover?
By the time of discharge, most patients are feeling well and only the occasional patient will require a prescription for pain-killers. Within a week, you will be back to normal daily activities. I would recommend that you not drive until there is full range of motion in your neck and the incision in your ankle or groin is no longer uncomfortable (generally about 2 weeks).
Are there alternative stroke treatments to carotid endartectomy?
Yes, carotid artery stenting (CAS) is a new procedure that appears promising. The procedure is done through a puncture in the groin. With the assistance of X-rays, a guidewire and a stent are manipulated from the femoral artery in the groin through the blockage of the carotid artery in the neck. A special device is also placed beyond the blockage that catches the debris that becomes dislodged during the procedure. The stent is deployed and the blockage gets pushed outwards and held in place by the radial force of the stent. Some small studies have shown that CAS and CEA have similar results in the short term. However, widespread acceptance of this technique has not occurred because of higher recurrence stenosis rates and because long-term studies have yet to be completed. Until these further studies are reported, CEA remains the standard of care.