Carotid Artery Surgery

Your doctor may recommend carotid artery surgery to treat carotid artery disease. Carotid artery disease is a buildup of plaque inside the carotid arteries. This narrows the carotid arteries and can eventually block them completely. This reduces blood flow to the brain and increases the risk of stroke. 

Your doctor may only recommend carotid artery surgery if other treatment options with less risk of complications have been ineffective. Ask your doctor about all of your treatment options and consider getting a second opinion before deciding on carotid artery surgery.

Carotid artery surgery treats carotid artery disease with any of the following conditions: 

• Carotid artery stenosis of 60% or greater. Carotid stenosis is a narrowing of the carotid arteries. Your doctor may decide that carotid artery surgery is a good treatment for you if your carotid arteries are narrowed by 60% or more. This is true even if you do not have symptoms and have not had a stroke or a TIA.

• Prior stroke, which occurs when the flow of blood to the brain stops

• Prior transient ischemic attack (TIA), a group of stroke-like symptoms that generally resolves within 24 hours. A TIA is a warning sign that you are at risk for a stroke.

The following specialists perform carotid artery surgery:

• Neurosurgeons specialize in the medical and surgical care of diseases and conditions of the brain, its blood vessels, and the nervous system.

• Vascular and interventional radiologists perform carotid angioplasty and stenting. These doctors specialize in the treatment of blood vessel and other conditions using catheter-based procedures and imaging techniques.

• Vascular surgeons specialize in surgical treatment of diseases of the blood vessels.

Your carotid artery surgery will be performed in a hospital using one of the following approaches:

• Catheter surgery is a form of minimally invasive surgery used for carotid angioplasty and stenting. It involves inserting a catheter through a vessel in a groin or elbow. X-ray imaging guides the catheter tip to the blocked area of the carotid artery. Your doctor performs the angioplasty using a balloon, laser or drill to open your artery. Your doctor can also place a stent using the catheter. A stent is a cylinder-like tube made of thin mesh. Stents remain in place to keep your artery open after angioplasty.

• Open surgery is used for carotid endarterectomy. Your surgeon makes an incision or cut in your neck to expose the diseased part of your carotid artery. Your surgeon either clamps your carotid artery closed or places a temporary shunt around your artery. The next step involves cutting open the diseased part of your artery and removing the inner lining, including the plaque buildup. Your surgeon closes your artery—sometimes this requires a “vein patch”—and unclamps it or removes the shunt. Open surgery allows your surgeon to directly view and access the surgical area. Open surgery generally involves a longer recovery and more pain than catheter surgery because it requires cutting and displacement of muscle and other tissues. Despite this, open surgery may be a safer or more effective method for some patients.

Your doctor will advise you on which procedure is best for you and how long you need to stay in the hospital based on your diagnosis, age, medical history, and general health. Learn about the different types of carotid artery surgery and ask why your doctor will use a particular type for you.
Types of anesthesia that may be used

Your doctor will perform carotid artery surgery using either general anesthesia or regional anesthesia, depending on the specific procedure. 

• General anesthesia is a combination of intravenous (IV) medications and gases that put you in a deep sleep. You are unaware of the surgery and do not feel any pain. You may also receive a peripheral nerve block infusion in addition to general anesthesia. A peripheral nerve block infusion is an injection or continuous drip of liquid anesthetic. The anesthetic flows through a tiny tube inserted near your surgical site to control pain during and after surgery.

• Regional anesthesia is also known as a nerve block. It involves injecting an anesthetic around certain nerves to numb a large area of the body. To numb a smaller area, your doctor injects the anesthetic in the skin and tissues around the procedure area (local anesthesia). You will likely have sedation with regional anesthesia to keep you relaxed and comfortable. For carotid artery surgery, your doctor will use local anesthesia to numb the incision area in your groin or elbow where he or she inserts the catheter. Your doctor may ask you questions during the procedure. This will help monitor your brain’s response to decreased blood supply if your carotid artery is clamped shut.

What to expect the day of your carotid artery surgery

The day of your surgery, you can generally expect to:

• Talk with a preoperative nurse. The nurse will perform an exam and ensure that all needed tests are in order. The nurse can also answer questions and will make sure you understand and sign the surgical consent form.

• Remove all clothing and jewelry and dress in a hospital gown. It is a good idea to leave all jewelry and valuables at home or with a family member. Your care team will give you blankets for modesty and warmth.

• Talk with the anesthesiologist or nurse anesthetist about your medical history and the type of anesthesia you will have.

• A surgical team member will start an IV. 

• The anesthesiologist or nurse anesthetist will start your anesthesia.

• A tube is placed in your windpipe to protect and control breathing during general anesthesia. You will not feel or remember this or the surgery as they happen.

• The surgical team will monitor your vital signs and other critical body functions. This occurs throughout the procedure and your recovery until you are alert, breathing effectively, and your vital signs are stable.

As with all surgeries, carotid artery surgery involves risks and possible complications. Complications may become serious and life threatening in some cases. Complications can develop during surgery or recovery. 

General risks of surgery 

The general risks of surgery include: 

• Anesthesia reaction, such as an allergic reaction and problems with breathing

• Bleeding, which can lead to shock

• Blood clot, in particular a deep vein thrombosis that develops in the leg or pelvis

• Infection
  

Potential complications of carotid artery surgery

Complications of carotid artery surgery include:

• Bleeding in the brain and brain damage

• Damage to an artery from the catheter or balloon

• Heart attack

• Hyperperfusion syndrome. This can occur when your brain suddenly receives normal blood flow after surgery. A severe headache that improves when you are upright is a classic symptom.

• Low blood pressure, which is usually temporary

• Nerve damage, which is usually temporary. This can make it difficult to swallow and cause numbness in your face.

• Restenosis, or re-blockage of your carotid artery

• Seizure (rare)

• Stroke

• Sudden vessel occlusion. This is a total blockage of the artery at the site of your angioplasty. Sudden vessel occlusion is a rare complication that typically occurs within 24 hours of angioplasty. It requires immediate medical attention.

• Throat swelling, making it difficult to breathe

Reducing your risk of complications

You can reduce the risk of some complications by following your treatment plan and:

• Following activity, dietary and lifestyle restrictions and recommendations before surgery and during recovery

• Notifying your doctor immediately of any concerns, such as bleeding, fever, increase in pain, or wound redness, swelling or drainage

• Taking your medications exactly as directed

• Telling all members of your care team if you have any allergies

You are an important member of your own healthcare team. The steps you take before surgery can improve your comfort and outcome. 

You can prepare for carotid artery surgery by:

• Answering all questions about your medical history and medications. This includes prescriptions, over-the-counter drugs, herbal treatments, and vitamins. It is a good idea to carry a current list of your medical conditions, medications, and allergies at all times.

• Getting preoperative testing as directed. Testing varies depending on your age, health, and specific procedure. Preoperative testing may include a carotid duplex ultrasound, CT scan, chest X-ray, EKG (electrocardiogram), blood tests, and other tests as needed.

• If you have high blood pressure, talk to your doctor about how to control it both before and after surgery. Good blood pressure control can help decrease your risk of complications with carotid artery surgery.

• Losing excess weight before the surgery through a healthy diet and exercise plan

• Not eating or drinking before surgery as directed. Your surgery may be cancelled if you eat or drink too close to the start of surgery because you can choke on stomach contents during anesthesia.

• Stopping smoking as soon as possible. Even quitting for just a few days can be beneficial and help the healing process.

• Taking or stopping medications exactly as directed. This may include not taking aspirin, ibuprofen (Advil, Motrin), and blood thinners.

Questions to ask your doctor

Facing surgery can be stressful. It is common for patients to forget some of their questions during a doctor’s office visit. You may also think of other questions after your appointment. Contact your doctor with concerns and questions before carotid artery surgery and between appointments. 

It is also a good idea to bring a list of questions to your appointments. Questions can include:

• Why do I need carotid artery surgery? Are there any other options for treating my condition?

• Which type of carotid artery surgery procedure will I need?

• How long will the surgery take? When can I go home?

• What restrictions will I have after the surgery? When can I return to work and other activities?

• What kind of assistance will I need at home?

• What medications will I need before and after the surgery? How do I take my regular medications?

• How will you treat my pain?

• When should I follow up with you?

• How should I contact you? Ask for numbers to call during and after regular office hours.

Knowing what to expect can help make your road to recovery after carotid artery surgery as smooth as possible. 

How long will it take to recover?

You will stay in the recovery room until you are alert, breathing effectively, and your vital signs are stable. You may have a drain in your neck to drain excessive fluids after a carotid endarterectomy. Your doctor usually removes the drains within a day. You may have a sore throat if a tube was placed in your windpipe during surgery. This is usually temporary, but tell your care team if you are uncomfortable.

A hospital stay of one to two days is usually needed. Some patients go home on the same day if surgery is early in the day and recovery is progressing well. 

Recovery after surgery is a gradual process. Recovery time varies depending on the procedure, type of anesthesia, your general health, age, and other factors. You will need to avoid strenuous activity and heavy lifting. Tell your doctor about all your activities and follow all instructions for returning to them. Full recovery takes a few days to several weeks.

Will I feel pain?

Pain control is important to healing and a smooth recovery. There will be discomfort after your surgery. It is unlikely that you will feel severe pain after carotid angioplasty. It is common to experience mild tenderness, bruising, and swelling at the catheter incision site. 

Your neck may hurt for several days after a carotid endarterectomy. You might also have discomfort when swallowing for a few days. Your doctor will treat your pain or discomfort so you are comfortable and can get the rest you need. Call your doctor if your pain gets worse or changes in any way because it may be a sign of a complication.

When should I call my doctor?

It is important to keep your follow-up appointments after carotid artery surgery. Contact your doctor for questions and concerns between appointments. Call your doctor right away or seek immediate medical care if you have:

• Bleeding

• Breathing problems, such as shortness of breath, difficulty breathing, labored breathing, or wheezing

• Change in alertness, such as passing out, dizziness, unresponsiveness, or confusion

• Chest pain, chest tightness, chest pressure, or palpitations

• Fever. A low-grade fever (lower than 101 degrees Fahrenheit) is common for a couple of days after surgery and not necessarily a sign of a surgical infection. However, you should follow your doctor's instructions about when to call for a fever.

• Inability to urinate or have a bowel movement

• Leg pain, redness or swelling, especially in the calf, which may indicate a blood clot

• Numbness, color change, or a feeling of coolness in the arm or leg that was used to insert the catheter

• Numbness or weakness on one side of your body or face, or severe headache

• Pain that is not controlled by your pain medication

• Sudden confusion, problems with speaking or memory, vision problems, dizziness, trouble walking, or loss of balance

• Swelling in your neck

• Unexpected drainage, pus, redness or swelling of your incision

How might carotid artery surgery affect my everyday life?

Carotid artery surgery may cure your condition so you can lead an active, normal life. It will not prevent carotid artery disease from coming back. You can make changes in everyday life that may help prevent or delay carotid artery disease, such as:

• Eating a heart-healthy diet

• Getting regular exercise

• Maintaining a healthy weight

• Practicing stress management techniques

• Quitting smoking

• Taking blood thinning medications, such as aspirin or clopidogrel (Plavix), as directed by your doctor

• Treating other related conditions, including high blood pressure, high cholesterol, and diabetes