Carotid artery surgery treats obstructions in the carotid arteries in order to restore healthy blood flow to the brain. There are two forms of carotid artery surgery: carotid endarterectomy (CEA) and carotid artery angioplasty with stenting (CAS). These are described in more detail below, but both procedures share the same goal: to help prevent stroke.
Carotid artery surgery is performed when a buildup of plaque has reduced the diameter of the carotid arteries; this is a potentially dangerous condition known as carotid artery disease. When carotid artery disease restricts blood flow, the brain cannot receive the oxygen and glucose it needs to function. When blood flow is restricted or absent, irreversible damage to the brain can happen quickly.
Carotid artery disease may endanger the blood flow to the brain in three ways:
Any of these scenarios can result in an ischemic stroke, a medical emergency that may cause disability or death.
Sometimes taking prescription medications and/or making lifestyle changes can control carotid artery disease. When these measures are insufficient, surgery may be necessary. Experienced neurosurgeons like those at Columbia Neurosurgery can help patients weigh the risks and benefits of nonsurgical and surgical treatments.
The two main types of carotid artery surgery are carotid endarterectomy (CEA) and carotid artery angioplasty with stenting (CAS).
Carotid endarterectomy (CEA) is a type of surgery that removes a plaque from an artery wall. To perform this delicate procedure, the surgeon uses very small instruments and an operating microscope that magnifies and lights the surgical field. This makes CEA a type of microsurgery.
A patient undergoing CEA always receives anesthesia, but the specific type varies by case. In some cases, local anesthesia and sedation are selected; in other cases, general anesthesia is preferable. The team weighs a number of factors and selects the best option before the day of surgery.
Chief among these factors is blood flow management. During CEA, it is expected that the blood flow to the brain is temporarily reduced. Our surgical team has a few options for managing this decrease.
A patient under local anesthesia is able to communicate with the operating team during surgery. Doctors speak with the patient to track cognitive function and grip strength, and in these ways monitor the brain’s response to changes in blood supply.
For patients under general anesthesia, the operating team monitors the brain’s blood supply using technology like electroencephalography, somatosensory evoked potential and transcranial doppler.
With either type of anesthesia, the surgical procedure for CEA is the same. A small incision is made in the front of the neck to expose the carotid artery. The surgeon clamps the artery to prevent bleeding. In some cases, the surgeon may use a shunt to divert blood flow from below the clamp to above the surgery site. In other cases, the brain receives adequate blood flow from the other carotid artery and a shunt is unnecessary.
Next the surgeon makes an incision in the carotid artery itself, exposing the plaque. The surgeon removes the inner wall of the artery and the attached plaque.
Then the surgeon closes the artery, either by means of sutures or a patch. The patch may be a manufactured item, or it may be a graft taken from a vessel elsewhere in the body. Finally, the surgeon closes the incision in the skin.
Carotid artery angioplasty and stenting (CAS) is a procedure that widens the narrowed artery by compressing the plaque and using a mesh tube to permanently prop the artery open. This procedure is conducted using very specialized equipment from inside the blood vessels themselves. This makes CAS a type of endovascular surgery (specifically, it is one type of percutaneous transluminal angioplasty). A traditional surgical incision is not required.
A patient undergoing CAS usually receives local anesthesia and sedation.
To perform CAS, the surgeon inserts a narrow catheter into a blood vessel in the groin. Using CT guidance, the surgeon guides the catheter through the blood vessels and into the carotid artery. Then the surgeon feeds a guide wire through the catheter and advances a second, even narrower, catheter over the guide wire. At the end of this second catheter are two devices: a stent and, inside it, a tiny deflated balloon.
When the balloon and stent are in the proper place in the carotid artery, the surgeon inflates the balloon. As it expands, the balloon presses against the stent, opening it wider. The stent props open the walls of the artery, allowing greater blood flow.
Then the surgeon deflates the balloon and removes it, along with the catheters and the guide wire. The stent remains in place. Over time, the walls of the artery will grow through and around the mesh of the stent.
In some cases, surgeons may be concerned that debris may break off the plaque during the procedure. In such cases, our surgeons may deploy an embolic protection device at the very end of the guidewire to catch any debris, minimizing the risk of stroke.
Make sure you understand the risks and goals of your procedure. It may help to write down questions as you think of them and bring your questions to your appointments.
Give your surgeon a complete list of your medications and their schedule. Ask if your medication schedule should be changed in any way for surgery.
If you smoke or otherwise use tobacco, quit. You may wish to ask your doctor for help quitting.
After a CEA, your neck may be sore, and swallowing may be difficult for a few days. You may wish to eat soft, smooth foods (soup, yogurt, pudding, etc.) until your neck returns to normal.
Hospital stay varies by case. You may be discharged from the hospital on the day of the procedure, or you may stay in the hospital for one or two nights.
Talk to your doctor about your ongoing treatment needs. Keeping an appropriate medication regimen and a healthy lifestyle will go a long way toward keeping your arteries healthy.
Dr. Robert Solomon, Dr. E. Sander Connolly, Dr. Sean Lavine, Dr. Grace Mandigo and Dr. Philip Meyers are experts in carotid artery surgery. Any of them can offer you a second opinion.
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