Carotid Surgery 

Overview

Every year in the United States, more than 795,000 people experience a stroke, according to the Centers for Disease Control and Prevention (CDC). The majority of these strokes are caused by carotid artery disease or atrial fibrillation, an abnormal heartbeat. According to the National Heart, Lung, and Blood Institute, carotid artery disease accounts for more than half of all strokes in the United States.

Carotid artery surgery (Carotid endarterectomy) is used to treat carotid artery disease. This condition develops when fatty, waxy deposits form in one of the carotid arteries. The carotid arteries are blood vessels on both sides of your neck (carotid arteries).

A stroke can occur as a result of carotid artery disease. Plaque or a blood clot that has clogged the artery can cause these obstructions. By doing a CEA, your doctor aids in the prevention of strokes by keeping blood flowing to your brain.

Carotid artery surgery also aids in the prevention of a transient ischemic stroke (TIA). A TIA features stroke-like symptoms, such as numbness, difficulty speaking or seeing, and difficulty walking, but they only last a short period.

A local or general anesthesia is used during carotid artery surgery. Your surgeon creates an incision in the front of your neck, opens your carotid artery, and removes the plaques that have blocked it. The artery is then repaired by your surgeon with sutures or a patch made from a vein or artificial material (patch graft).

A method known as eversion carotid endarterectomy is sometimes used by surgeons. This procedure entails severing the carotid artery and turning it inside out before removing the plaque. The artery is then reattached by your surgeon.

 

Carotid Arteries Anatomy

We'll begin at the carotid arteries origin. The right common carotid artery develops from a brachiocephalic trunk bifurcation (the right subclavian artery is the other branch). This bifurcation happens around the right sternoclavicular joint.

The left common carotid artery emerges straight from the aortic arch. The common carotid arteries, left and right, rise up the neck, lateral to the trachea and oesophagus. They don't produce any branches in the neck.

The carotid arteries divide into external and internal carotid arteries at the upper border of the thyroid cartilage (C4). This bifurcation occurs in the carotid triangle, which is an anatomical region.

The common and internal carotid arteries are somewhat dilated here, forming the carotid sinus, which is crucial in monitoring and controlling blood pressure.

 

What is Stroke & its Symptoms?

Stroke happens when the blood flow to the brain is reduced or blocked. A stroke victim requires prompt emergency treatment.

In the United States, stroke is the sixth highest cause of death. Every year, about 800,000 people experience a stroke. That equates to around one person every 40 seconds.

There are three main types of stroke:

1. Ischemic stroke: The most frequent kind of stroke, accounting for 87% of all instances. A blood clot restricts the flow of blood and oxygen to a specific part of the brain.
2. Hemorrhagic stroke: It is caused by a ruptured blood artery. These are often caused by aneurysms or arteriovenous malformations (AVMs).
3. Transient ischemic attack (TIA): This occurs when blood supply to a specific area of the brain is insufficient for a short period of time. After a short period, normal blood flow resumes, and the symptoms disappear without therapy. This is known as a mini-stroke by some.

Stroke is potentially fatal. According to the American Heart Association (AHA), the age-adjusted mortality rate for stroke diagnoses in 2017 was 37.6 per 100,000 strokes. Doctors have made significant improvement in stroke management, therefore the fatality rate is 13.6 percent lower than it was in 2007.

Signs and symptoms of stroke include:

• Having difficulty speaking and understanding what people are saying. You may become confused, slur your words, or have difficulties understanding conversation.
• Face weakness, arm, or leg paralysis or numbness. You might have abrupt numbness, weakness, or paralysis in your face, arm, or leg. This usually only affects one side of the body. Try raising both arms above your head at the same moment. You may be experiencing a stroke if one of your arms begins to fall. When you try to smile, one side of your lips may droop.
• Vision problems in one or both eyes You may have blurred or darkened vision in one or both eyes, as well as seeing double.
• Headache. A sudden, severe headache, maybe followed by vomiting, dizziness, or altered consciousness, may suggest a stroke.
• Walking is difficult. You could stumble or lose your equilibrium. You might also experience dizziness or lack of coordination.

 

Who Needs to Have a Carotid Surgery?

A vascular surgeon will evaluate you to determine whether a carotid endarterectomy is appropriate for you:

• Assess your medical history.
• Perform diagnostic tests.

You and your doctor will decide whether to seek surgical treatment. This surgery is carried out in a hospital surgical suite by a vascular surgeon.

If you have the following symptoms, your doctor may advise you to have a carotid endarterectomy:

• Suffer from carotid artery disease.
• Had a transient ischemic attack (TIA) or a minor stroke as a result of substantial carotid artery disease.
• Have a substantial narrowing or blockage in your carotid artery (typically at least 80%) but no symptoms of this condition.

If a carotid surgery is not the best option for you, your doctor may recommend that you have your carotid artery checked once a year. To avoid a stroke, you may need to change your diet and start taking blood thinners like aspirin or clopidogrel. 

To keep your carotid artery open, your physician may perform an angioplasty (which presses plaque against the walls of your carotid artery to improve blood flow) and insert a stent (mesh tube).

 

What Happens Before Carotid Artery Surgery?

In addition to a physical check-up, you may be subjected to tests a few days before your treatment to determine that the surgery is safe to perform. A cerebral angiography may be ordered by your surgeon to better identify the architecture of your brain. A cerebral angiography is an invasive diagnostic technique that creates X-ray images of the inside of your brain's blood arteries.

However, in many instances, your healthcare physician may now obtain this information via a CT or MR angiography. These are noninvasive ways for obtaining information about your carotid arteries and brain that may be conducted without the risk of a stroke.

Your healthcare team will give you specific instructions to help you prepare for your procedure: 

1. Your healthcare professional will explain the process to you, and you will have the opportunity to ask questions.
2. You will be asked to sign a consent form giving permission to do the surgery. If something is unclear, read the form carefully and ask questions.
3. Before the treatment, your healthcare professional will evaluate your medical history and do a physical assessment to ensure you are in overall excellent health. 
4. You may be subjected to blood testing or other diagnostic procedures.
5. Inform your doctor if you are sensitive to or allergic to any medications, iodine, latex, tape, contrast dye, or anesthesia.
6. Inform your doctor about all prescription and over-the-counter medications, as well as herbal supplements you are using.
7. Inform your doctor if you have a history of bleeding issues. Also inform your provider if you are using any blood-thinning (anticoagulant) medications, aspirin, or other medications that alter blood clotting. Some of these medications may be discontinued prior to the operation.
8. Inform your healthcare practitioner if you are pregnant or suspect you might be.
9. Follow any instructions for avoiding eating or drinking before surgery.
10. Before the treatment, your healthcare professional may require a blood test to determine how long it takes your blood to clot.
11. You may be given sedative medication before to the surgery to help you relax.
12. If you have a pacemaker, inform your doctor.
13. Stop smoking as soon as possible before the operation if you smoke. This may aid in your recovery. It may also benefit your overall health. Smoking increases the likelihood of blood clots.
14. Your healthcare practitioner may offer you additional preparation instructions based on your situation.
15. Think positively - Having a good mental attitude will help you deal with the stress of surgery and recover faster.

 

What Happens During a Carotid Surgery?

Carotid Surgery requires a stay in hospital. Procedures may vary based on your condition and your healthcare provider's practices.

Generally, carotid Surgery follows this process:

1. You will be requested to take off any jewellery or other anything that might obstruct the operation.
2. You will take off your clothes and change into a hospital gown.
3. Before the procedure, you will be asked to empty your bladder.
4. An intravenous (IV) line will be inserted into your arm or hand. A second catheter will be inserted into your wrist to monitor your blood pressure and collect blood samples. To monitor your heart, one or more additional catheters may be inserted into your neck, opposite the operation site. The catheter can also be placed beneath the collarbone and in the groin.
5. If the surgery location has too much hair, the healthcare personnel may shave it off.
6. You will be positioned on the operation table on your back. Your head will be slightly elevated and turned away from the side being operated on.
7. To drain urine, a catheter will be inserted into your bladder.
8. During the procedure, the anesthesiologist will monitor your heart rate, blood pressure, breathing, and blood oxygen level.
9. Carotid surgery can be performed under local anaesthetic. You will be drowsy, but you will not feel the operation. Before the treatment, you will be given a sedative through IV to help you relax. This allows the healthcare expert to monitor your progress during the process by asking questions and assessing your hand grip strength.
10. If the carotid surgery is performed under local anesthetic, the healthcare practitioner will offer you with constant support and ensure that you are comfortable during the process. You will be given pain medication as needed.
11. You will be given oxygen through a nasal tube while under local anaesthetic.
12. A carotid surgery can also be performed while under general anesthesia. This means you'll be sleeping. After you've been sedated, the provider will insert a breathing tube into your neck and windpipe to supply air to your lungs. You'll be hooked up to a ventilator. During the procedure, this machine will breathe for you.
13. Antibiotics will be administered via IV to assist prevent infection.
14. The healthcare personnel will use an antiseptic solution to clean the skin around the operation site.
15. A cut (incision) will be made down the side of the neck over the diseased artery by the healthcare professional. Once the artery has been revealed, the provider will make an incision into it.
16. To redirect blood flow around the operation region, the healthcare professional may use a device known as a shunt. This will maintain blood flow to the brain. A shunt is a tiny tube that is inserted into the carotid artery to direct blood flow around the surgical site.
17. The healthcare expert will remove the plaque from the artery while the blood flow is redirected.
18. The shunt will then be removed and the artery will be gently closed. The neck incision will be stitched together.
19. A small tube (drain) may be inserted through your neck. This will drain any blood into a little suction bulb the size of a palm. It is usually removed the next morning following the surgery.
20. To keep your blood pressure within a specified range, you may be given blood pressure medication by IV during and after the treatment.
21. If you were given general anesthesia, the doctor will wake you up in the operating room to ensure you can reply to questions.
22. The surgical site will be covered with a sterile bandage or dressing.

 

What Happens After a Carotid Surgery?

In the hospital:

• You will be brought to the recovery room following the procedure. You may be transported to the intensive care unit (ICU) or your hospital room after your blood pressure, pulse, and breathing are stable and you are alert.
• You will be helped out of bed and allowed to walk around as soon as you are able.
• If a drainage tube was inserted in the incision during the treatment, it will most likely be removed the next morning by your healthcare professional.
• You will be given solid foods as you are able.
• As directed by your healthcare professional, take a pain reliever. Aspirin and other pain relievers may raise the risk of bleeding. Take just the medications that have been prescribed to you.
• Your healthcare provider may schedule you for follow-up duplex ultrasound procedures to monitor the carotid arteries in your neck.
• Generally, you can go home within 1 to 2 days after a carotid Surgery.

 

At home:

It is critical to keep the incision area clean and dry once you return home. Bathing instructions will be provided by your healthcare provider. Stitches will be removed during a follow-up appointment visit if they are used. If you use adhesive strips, keep them dry or they will slip off after a few days.

Unless your doctor advises you otherwise, you can resume your usual diet. It is typically recommended to have a low-fat, low-cholesterol diet. Vegetables, fruits, low-fat or nonfat dairy products, and lean meats are all recommended. Processed or packaged foods should be avoided.

Tell your healthcare provider to report any of the following:

• Fever or chills.
• Redness, swelling, or bleeding or other drainage from the incision site.
• Increased pain around the incision site.

 

Risks or Complications of Carotid Surgery

As with any surgery, there is a risk of complications, including:

• Bleeding.
• Infection.
• Blood clots.
• Nerve damage.
• Seizures.
• Brain damage.
• Future artery blockage.
• Stroke. (This happens in 5% to 7% of people who already had a stroke or mini-stroke and 2% to 3% of those who did not.)
• Heart attack.

However, with an experienced surgeon, there's minimal risk. The risks of a carotid Surgery vary, depending on:

• The severity of your carotid artery disease.
• The location of the blockage.
• Whether you've had a previous stroke.
• The presence of other coexisting medical conditions, such as diabetes or kidney disease.
• Your age. (Older people are at a higher risk.)
• Your gender. (People assigned female at birth may have a higher risk of complications.)

If your healthcare practitioner suggests this operation as a therapy option for you, discuss why they recommend it, the advantages and risks, and the hospital's surgical outcomes.

While the procedure may cause some neck pain for approximately two weeks following, you may treat it with conventional, over-the-counter pain medications.

 

When Should I See My Healthcare Provider?

Contact your healthcare provider if you have:

• Chills or fever.
• Blood or yellow or green mucus when you cough.
• Trouble swallowing.
• Chest pain.
• Swollen legs.
• A hard time being able to see.
• Dizziness.
• Weakness or numbness in your body.
• Shortness of breath.
• Redness on your incision or green or yellow discharge coming out of it.
• A headache, confusion or difficulty speaking or understanding others’ words.

 

Conclusion

The carotid arteries, which are placed on each side of your neck, supply the oxygen-rich blood that your face and brain require to function correctly.

Your brain cells would die if there was no blood supply. A stroke can occur when blood flow to a specific part of the brain is restricted or obstructed. Strokes can be deadly or cause temporary or permanent mental and physical damage.

When you have carotid artery disease, a material called plaque, which is made up of fat, cholesterol, and calcium, builds up in your artery and narrows it. This narrowing is known as stenosis, and it can impede blood flow.

A procedure known as carotid surgery is one method for removing obstructions in the normal flow of blood and lowering your chance of having a stroke. 

Recovery times vary, and you may need to stay in the hospital overnight for monitoring. Your doctor will want to make sure you don't have any bleeding, inadequate blood supply to your brain, or other stroke risk factors. The majority of patients are discharged within 24 hours.