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Carotid endarterectomy for TIA and stroke

Surgery Overview

Carotid endarterectomy is surgery to remove plaque buildup in the carotid arteries. During a carotid endarterectomy:

• A small incision is made in the neck just below the level of the jaw. The narrowed carotid Artery is exposed.
• The Blood flow through the narrowed area may be temporarily rerouted (shunted). Rerouting is done by placing a tube in the vessel above and below the narrowing. Blood flows around the narrowed area during the surgery.
• The artery is opened and the plaque is carefully removed, often in one piece.
• A Vein from the leg may be sewn (grafted) on the carotid artery to widen or repair the vessel.
• The shunt is removed, and the artery and Skin incisions are closed.

What To Expect After Surgery

The surgery often takes about an hour. Recuperation includes spending a short time in the Recovery room and may include about 24 hours in the intensive care unit to watch for complications.

The hospital stay usually is 1 to 3 days, and normal activities can be resumed within a week as long as the activities are not physically demanding. There may be some aching in the neck for up to 2 weeks. It is important not to turn your head too often or too quickly during your recovery.

Why it Is Done

Carotid endarterectomy may be indicated if you:

Have had a transient ischemic attack (TIA) or Stroke caused by a narrowing of greater than 70% in the carotid artery.

• Have had a TIA or mild stroke in the past 6 months, but the stroke did not leave you completely disabled, and your carotid arteries are at least 50% narrowed. In this case, surgery is more effective than medicines at preventing future strokes.
• Have not had a TIA or stroke, but your carotid arteries are narrowed 60% or more and you have a low risk of complications from the surgery.

Those most likely to benefit from surgery are people who have had symptoms that can be attributed to a 70% or greater narrowing (stenosis) of their carotid artery. People with less than 50% narrowing do not seem to benefit from surgery.

How Well It Works

Several large studies have shown that carotid endarterectomy reduces the risk for transient ischemic attack (TIA) and stroke in people with moderate to severe narrowing (70% to 99%) of the carotid arteries.This is true for people who have evidence of plaque buildup in the carotid arteries and also are at low risk for complications from the surgery, regardless of whether they have had a TIA or stroke.

Carotid endarterectomy is 3 times more effective than treatment with Medicine alone in preventing stroke for people who have symptoms that can be attributed to a 70% to 99% blockage of the carotid arteries.

Risks

The major risks associated with carotid endarterectomy are:

• Stroke.
• Heart attack. Most deaths that occur during a carotid endarterectomy are caused by a Heart attack.
• Heart and breathing difficulties, high Blood pressure, Infection, injury to nerves (usually causing Vocal cord paralysis and problems with managing saliva and tongue movement), and bleeding within the Brain.
• Plaque buildup, which may redevelop as a late complication between 5 months and 13 years after surgery.
• Death.

One study showed that some of these risks may be reduced by taking statin medicines before surgery. People in the study who had taken a statin for at least a week before surgery were much less likely to have a stroke or die than those who did not take a statin.³

Although this study is promising, more research is needed. If you are planning to have this surgery, talk to your doctor about the risks and the benefits of taking a statin before surgery.

What To Think About

Carefully weigh the benefits and risks of surgery, and compare them with the benefits and risks of Medication therapy. The success of medication therapy will depend on how much narrowing (stenosis) is present in the arteries and the choice of medicine. Risks of surgery depend on your age, your overall health, the skill and experience of the surgeon, and the experience of the medical center where the surgery is done.

Tests such as carotid Ultrasound, carotid arteriography, CT angiography, or magnetic resonance angiography (MRA) are needed before surgery to evaluate the amount of plaque buildup in the carotid arteries and the flow of blood through the narrowed area. (For more information, see the Exams and Tests section of the topic Stroke.) The blood vessels beyond the hardened area are also evaluated; if those vessels are severely damaged, surgery may not be helpful.

While carotid endarterectomy can be done several months after a TIA, a recent large study showed that people benefit most from the surgery if it is done within 2 weeks of a TIA. Delaying surgery longer than 2 weeks increases the risk for stroke because people are more likely to have a stroke in the first few days and weeks after a TIA. This study points out why it is so important to see your doctor immediately if you have any signs of TIA.

The likelihood of complications from carotid endarterectomy varies, depending on the skill and experience of the surgeon. The American Heart Association Stroke Council recommends that surgery be performed by a surgeon who has complications in less than 3% of the endarterectomy surgeries that he or she performs and that the hospital rate of complications be just as low.

• Before surgery, any medical condition that increases the risk for stroke, such as high blood pressure or heart disease, needs to be controlled.
• The benefits of surgery may be temporary if underlying disease or causes are not also treated. Using long-term aspirin treatment, getting regular exercise, lowering cholesterol levels, Eating a low-fat diet, and quitting smoking are important aspects of postsurgery treatment.

Most experts agree that carotid endarterectomy is not recommended for people with:

• Transient ischemic attacks (TIAs) that are occurring because of narrowed blood vessels in the back of the brain (vertebrobasilar arteries).
• Significant disease of the arteries supplying the heart (coronary arteries) or uncontrolled high blood pressure.
• Severe hardening of the arteries (Atherosclerosis) that reduces blood flow in the vessels that branch off from the carotid arteries within the skull.
• Significant problems with your carotid arteries above the part of the neck that can be reached easily during surgery. It is more difficult to operate on the arteries that are above the neck, where they enter the skull. Tests such as a magnetic resonance angiography (MRA) can help show whether there are problems in this area.
• Other serious medical problems, such as Kidney Failure or Heart Failure, that would make surgery more risky.

Research is ongoing to determine whether surgery is beneficial for people who do not have symptoms of narrowing in their carotid arteries but who have a high risk of stroke.

References

Citations

1. Biller J, et al. (1998). Guidelines for carotid endarterectomy: A statement for healthcare professionals from a special writing group of the Stroke Council of the American Heart Association. Circulation, 97(5): 501–509.

2. Barnett HJM, et al. (1998). Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. New England Journal of Medicine, 339(20): 1415–1425.

3. McGirt MJ, et al. (2005). 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors reduce the risk of perioperative stroke and mortality after carotid endarterectomy. Journal of Vascular Surgery, 42(5): 829–836.

4. Rothwell PM, et al., (2004). Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet, 363(9413): 915–924.

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Carotid endarterectomy for TIA and stroke Keyword

Transient Ischemic Attack (TIA) , Vocal cord paralysis , Atherosclerosis , Kidney Failure , Blood pressure , Heart Failure , Heart attack , Medication

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