CAROTID ENDARTERECTOMY
Patient Information Leaflet
What does the carotid artery do ?
The carotid artery carries blood from the heart to part of the brain. There are 2 carotid arteries, one on each side of the neck. At the level of jaw these arteries divide into 2 branches - the internal and external carotid arteries. It is the internal carotid artery that supplies blood to the brain and the eye. The external carotid artery supplies the face, nose, mouth and upper neck.
What problems can arise from atheroma in this artery ?
Various risk factors (including smoking, high blood pressure, high cholesterol and diabetes) contribute to cause damage to the inner lining of the artery. Over time, fat accumulates in the muscle cells of the artery eventually leading to the formation of an 'atheroma plaque' (commonly called 'furring up' or 'hardening' of the artery). The outer surface of this plaque is hard and contains calcium. The inner core is soft and like porridge. If the outer shell cracks, some of the 'porridge' may dislodge and travel to the brain (causing a stroke or 'mini-stroke') or to the eye causing temporary blindness in the eye on the same side. Clot may form on the crack and this may also dislodge and travel towards the brain. If the artery becomes completely blocked by this process, a dense stroke may result.
What is TIA and amaurosis fugax ?
When thinking of symptoms caused by carotid disease, we have to remember that the right side of the brain controls and receives information from the left side of the body, whereas the left side of the brain deals with the right side of the body.
If a small amount of debris or clot travels to the brain from the carotid artery, it may cause a small part of the brain to be deprived of its blood supply. This causes symptoms and signs suggestive of a stroke (i.e. weakness of the face, arm or leg; altered sensation in these areas; or, sometimes difficulty with understanding speech or talking). If the problem goes away completely within 24 hours, it is referred to as a transient ischaemic attack (TIA) or mini-stroke . If the problem persists beyond 24 hours but there is excellent recovery then it is known as a minor stroke. The carotid artery responsible will be on the opposite side to the body part affected. A TIA indicates that you are at higher risk of a major stroke within the next year.
If the debris or clot travels to the eye, it may cause temporary blindness in one eye. This is called amaurosis fugax and is often described as a curtain descending across the eye. Sometimes the debris may be seen in the artery at the back of the eye by your optician. The carotid artery responsible will be on the same side as the affected eye.
What investigation will I need ?
The specialist will take a detailed history to see if your symptoms fit with possible disease of the carotid artery. You will need a duplex scan of the carotid arteries. A duplex scan is a combination of an ultrasound scan (this gives a picture of the arteries) and doppler (this gives an idea of blood flow in the artery). On the screen you will see red and blue colours indicating blood flow in the artery. By measuring the speed at which the blood is flowing through the narrowed segment, it is possible to work out how severe the narrowing is.
Sometimes, it may be necessary to use other tests such as angiography, CT scan or MRI.
You may need a scan of your heart and a heart tracing (ECG) to see if the blood clot could have come from here.
Do all patients need an operation ?
Only a fraction of TIAs will be due to carotid disease. Of these, surgery will only benefit those patients who have more than 70% narrowing in the carotid artery.
All patients will also be given aspirin to help thin the blood slightly and make it less sticky (other tablets are available if you cannot tolerate aspirin). They may also need tablets to control blood pressure and blood cholesterol levels. All patients who smoke will be requested to s. This is called 'best medical management'. If you have less than 70% narrowing, this is all you will need. You do not need an operation.
If you have more than 70% narrowing on the appropriate side, your specialist will discuss surgery with you. The aim of surgery is to decrease your long-term risk of a major stroke. The operation, however, carries a small risk of stroke with it. The benefits to you outweigh this risk.
What happens before the operation ?
About a week before your operation, you will be requested to attend the hospital for a pre-admission clinic. Here you will be seen by a juniour doctor who will take a history from you and examine you. Please remember to bring all your tablets to this clinic. Blood tests, a heart tracing (ECG) and a chest x-ray, if necessary, will be taken.
When a bed has been confirmed for you (you will have to telephone the hospital to check this) you can make arrangements to come to the hospital. You will need to bring with you soap, flannel, tooth brush and paste, comb/brush, shaving equipment if used, towel, night wear, dressing gown and slippers. Do not wear make up or nail polish. Do not bring valuables or too much money - only bring sufficient for a few telephone calls.
You will usually be admitted the day before your operation. When you are admitted to the ward, the nurses will show you around the ward and again confirm all of your details.
You will be seen by the consultant surgeon on the evening before your operation when all details will be explained to you and you will be requested to sign a consent form. The anaesthetist will also see you before the operation. You will be required to starve form mid-night.
On the day of the operation a duplex scan may be carried out to ensure that there has been no change in the degree of narrowing. You will be required to change into a theatre gown. A nurse and porter will accompany you to the operating theatre where you will be greeted by the anaesthetic assistant and all of your details confirmed again.
In the anaesthetic room
The anaesthetist will insert a needle into the back of your hand. Through this drugs can be given which will make you go to sleep - this is a general anaesthetic. A tube is inserted into your windpipe so that a machine (ventilator) can breathe for you. Once you are asleep, a needle will be inserted into the small artery at your wrist. This will allow us to keep a very close eye on your blood pressure throughout the operation. A tube may be inserted into your bladder so that we can monitor the amount of urine you produce - also you do not need to worry about passing urine after the operation as it will automatically drain into a bag.
In the operating room
After you have been positioned on the operating table the neck is cleaned with antiseptic and sterile drapes are positioned to create a clean operating area. A cut is made in the neck on the side of the affected artery. The arteries are then dissected out, clamped and opened. The atheroma inside the artery is cored out carefully ensuring all loose material is removed. The opened artery is then closed with a 'patch' to ensure the artery remains wide and does not narrow down. The patch may be vein taken from your arm or a piece of polyester specially designed for this purpose ('dacron'). To prevent the collection of blood in the wound a drain is sometimes inserted before closing the tissues and skin. The whole operation takes about one and a half hours.
What are the complications of the operation ?
The majority of operations are straightforward but the following complications are possible:
 | Bleeding - during and after the operation. Sometimes a collection of blood may form after the operation - you may need to be taken back to theatre to drain this blood as it can press on the windpipe, making it difficult for you to breathe. |
| Stroke - this is uncommon and affects 1or 2 cases in 100 who have the operation. It may be minor (like a TIA) or major. |
| Death - can occur after this operation. Most are due to heart problems. Occasionally the stroke may be major enough to cause death. This can occur in 1 or 2 cases out of 100 having the operation. |
| Wound infection - is uncommon. Most are superficial and settle rapidly with antibiotics. The dacron patch may rarely become infected - this may need futher surgery to correct the problem. |
| Nerve damage - there are various nerves that can de damaged during the operation. These include skin nerves supplying the neck, nerves that move your tongue and nerves that control your voice (damage to these may cause hoarseness). |
| Blood pressure - problems may occur immediately after the operation with the pressure going very high or very low. Drugs will be needed to control this problem. |
After the operation
After the operation you will be taken to the recovery area where a nurse will monitor your progress closely. Once you have recovered from the operation you will be taken to the HDU (high dependency unit) where you will be monitored overnight before returning to the ward the following day. Before returning to the ward the needle in the artery at the wrist will be removed.
On the ward, if a drain was used this will be removed. The tube in your bladder will also be removed. You will be encouraged to keep active on the ward. If everything goes to plan you will be allowed home 2 days after your operation.
Back at home
The wound can be left exposed after the third day. You can get it wet but avoid soaking it in a bath. Try to stay as active as possible.
Take your medication regularly (including the aspirin). Take your pain-killers regularly for the first few days.
Do not drive for the first week. Return to full activities and work when you feel up to it.
Contact your GP if:
| the wound starts to leak, looks red or becomes more painful. |
| you feel generally unwell e.g. dizzy, persistent headaches etc |
| if you experience further TIAs or amaurosis fugax |
An appointment will have been made for you to return to the hospital for a check-up 6-8 weeks after the surgery.
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