Carotid Endarterectomy

This is still the procedure of choice in most patients with symptomatic carotid stenosis. Carotid stenting continues to play a role, though its place is a little more conjectural.

Pre-operative preparation

In order to prepare for this procedure, it is vital that a full medical work-up be obtained to confirm fitness for anaesthesia.

This will involve a number of blood tests, and an assessment of the heart with an ECG, thallium scan, and referral to a cardiologist if there are any concerns about your heart.

Day of procedure

You may be admitted on the morning of the procedure if your work-up has been completed. You will be required to bring ALL of your usual medications. I am usually happy for you to continue blood thinners such as aspirin or clopidogrel. Warfarin however does need to be ceased at least 3 days before the procedure.

It is important to fast for at least 6 hours prior to the procedure. For a morning procedure, you will need to fast from midnight, whereas for an afternoon procedure, this will mean fasting from 7am.

Your anaesthetist will consult you prior to the operation, and explain the anaesthetic and its risks to you.

The procedure

A full general anaesthetic is administered, and a tube inserted into your windpipe (trachea) to help with your breathing while you are asleep. An intravenous line is inserted for the administration of anaesthetic agents during the procedure.

The operation is performed through an oblique incision on the side of the neck.

The carotid artery is exposed, with care taken to identify and preserve the hypoglossal and vagus nerves. A nerve responsible for sensation to the angle of the jaw is invariably divided, and this is responsible for some numbness in that region.

Heparin is administered to help keep the blood thin. The carotid artery and its main branches are clamped, the vessel opened, and a shunt inserted to maintain flow to the brain. The plaque responsible for the narrowing is removed meticulously, resulting in a carotid free of any residual plaque. The artery is then closed either by closing the vessel directly with a continuous suture, or by using a patch (synthetic or vein), thereby enlarging the carotid, which is necessary in some cases. Just before closure is complete, the shunt is removed.

The wound is closed with dissolvable sutures and a suction (redivac) drain is often inserted though generally removed within 24 hours

Post-operative course

All patients are closely monitored for the first few hours to ensure there has been no further neurological event.

Diet can be resumed after 4 hours if all is well, and most patients are fully ambulant the next day.

Most patients are fit for discharge within 48 hours of the procedure.

What are the possible complications?

Stroke and heart attack (myocardial infarction) are the two major risks. Overall the risk of a major stroke is about 1%, which is much lower than the risk of stroke if the carotid is left untreated. The risk of heart attack is also 1%.

Bleeding can occur particularly in patients already on blood thinners (aspirin, clopidogrel). This may cause some bruising in the wound. On rare occasions, patients may return to the operating theatre to have the bleeding controlled or a wound haematoma (collection of blood) evacuated.

Nerve injuries to the vagus or hypoglossal nerve are very uncommon, but if it occurs can affect the voice or movement of the tongue.