What Is Carotid Endarterectomy?
Carotid endarterectomy is a surgical procedure that involves removing plaque from the carotid arteries in the neck.
Everybody has two carotid arteries in the neck — one on each side. Plaque buildup in these arteries, also called atherosclerosis, can cause them to narrow.
This can restrict blood flow to the brain, or a small piece of plaque might break loose, leading to a stroke or a transient ischemic attack, also called a TIA or mini-stroke.
Carotid endarterectomy is an evidence-based treatment that reverses narrowing of carotid arteries, or carotid stenosis. The goal is to restore normal blood flow to the brain by removing the plaque, preventing a stroke or a secondary stroke.
Conditions Treated with Carotid Endarterectomy
Carotid endarterectomy is usually recommended to treat the following two groups of patients:
- Patients with asymptomatic, high-grade carotid stenosis: These patients aren’t currently having any stroke symptoms, but their carotid arteries are highly narrowed. Usually, surgery is recommended if the degree of stenosis is more than 80%. But this can change depending on the case. The timing is not extremely urgent — it can be done within months of the diagnosis. The purpose of the procedure is to avoid future stroke or TIA
- Patients who have symptoms of stroke or TIA: Symptoms are neurological and may include changes in speech or vision, numbness or weakness, confusion or loss of balance. For these patients, surgery is recommended within a few days or weeks to avoid further episodes of stroke.
How the Carotid Endarterectomy Procedure Works
When you come in for carotid endarterectomy, the surgeon will first take an ultrasound of your carotid artery. This imaging will help them locate exactly where the plaque is in the artery and make as small an incision as needed.
Throughout the surgery, your team will monitor your brain. They may use an electroencephalogram, or EEG, which involves placing electrodes on the scalp. They may also use somatosensory evoked potential, or SSEP, which tracks how your nerves are transmitting signals from your body to your brain. Other tools they may use include oximetry to measure oxygen levels in the blood and transcranial doppler, or TCD, to measure blood flow.
Monitoring is important because the surgery involves temporarily stopping blood flow to the brain through the carotid artery. If your team notices any changes in brain function during your procedure, they may insert a temporary shunt that will restore blood flow while the surgery is performed.
The procedure can be done while you are under local anesthesia or general anesthesia. Most carotid endarterectomy procedures are performed under general anesthesia.
You will be given a blood thinner to prevent clotting. Then, the surgeon will make an incision, usually less than two inches long, in the neck.
The carotid artery has three layers. To remove the plaque, the surgeon will remove the inner layer and part of the middle layer, leaving the other part of the middle layer and the outer layer.
Once the plaque is removed, the surgeon will close the incision. They may close the artery primarily, which means they will suture it closed. Or they may insert a patch, which acts like a roof on top of the artery so it won’t narrow over time.
The surgery takes about two hours or less. Most patients go home the next day. In rare cases, some patients may stay in the intensive care unit to monitor blood pressure and heart rate.
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Benefits of Carotid Endarterectomy Surgery
The major benefit of carotid endarterectomy surgery is that it greatly reduces the risk of stroke. It improves blood flow to the brain by completely removing plaque from the carotid artery.
For a patient who has had a stroke before, it can prevent another one from happening. And for a patient with high-grade stenosis who doesn’t have symptoms, it can prevent a primary stroke.
The procedure is well studied and has been practiced and improved for decades. It has been shown to be very durable, meaning its benefits last a long time. Recurrent disease, when plaque builds up in the artery again after surgery, is rare and generally only happens in patients who do not take steps to reduce risks, such as smoking, high cholesterol, diabetes or high blood pressure.
Following surgery, patients are monitored by ultrasound to keep an eye on the surgical site and make sure their condition doesn’t get worse.
Is Carotid Endarterectomy Right for Me?
Carotid endarterectomy may be right for you if you have high-grade carotid artery stenosis. That means your carotid artery has narrowed by 70-80% or more.
This puts you at high risk for stroke, even if you haven’t had any symptoms, particularly in healthy patients. And if you’ve had a stroke in the past, high-grade stenosis means you have greater risk of having another one.
You will need a full evaluation from a specialist to know for sure whether this procedure is right for you.
There are some cases where carotid endarterectomy is not recommended for patients with high-grade stenosis. That’s why it’s important to be evaluated to see if you are a candidate. Our specialists are experts in both open surgery and carotid stenting. They will make an informed decision on the best approach for you.
Your surgeon may recommend a different procedure if any of the following apply to you:
- You have severe heart and/or lung disease
- You aren’t a good candidate for general anesthesia
- You’ve had radiation treatment for cancer in the head or neck
- You’ve had a previous carotid endarterectomy or neck dissection
If your carotid artery narrowing is mild or below 80%, your specialist may advise other treatments, including medications for blood pressure or cholesterol, blood thinners, diabetes control and quitting smoking. They will likely also monitor your artery narrowing to make sure it does not progress.
Choosing Rush for Carotid Artery Surgery and Stroke Prevention
- Nationally recognized stroke and vascular care: U.S. News & World Report includes Rush on its Best Hospitals Honor Roll and ranks our heart, vascular, neurology and neurosurgery care among the best in the nation.
- Experienced surgeons: Our surgeons have performed thousands of carotid artery surgeries with excellent results. They rely on that experience and perform thorough evaluations to ensure they recommend the most appropriate treatments for you. They are experts at minimizing surgical risks and scarring, making your safety their top priority.
- Advanced imaging and diagnostics: Our specialists have access to advanced ultrasound technology to pinpoint the location of plaque in your arteries. This allows them to make minimal incisions, which reduces risks and improves recovery time. They also rely on tools like EEG, SSEP, TCD and oximetry to monitor your brain and blood flow during surgery and preserve neurological function.
- Collaborative care: Our vascular surgeons work closely with neurologists, neurosurgeons and stroke experts, giving you access to a team of specialists who tailor your care plan to your specific needs. Our Stroke Prevention Clinic also provides you with custom options for continuing care, including medications, help with lifestyle changes and nutrition counseling, that empower you to prevent a primary or secondary stroke in the future.
FAQs About Carotid Endarterectomy
Carotid endarterectomy is performed to remove plaque that has built up in the carotid artery. The goal in removing this plaque is to prevent a primary stroke in patients who have high-grade carotid artery stenosis but haven’t had symptoms, or to prevent another stroke in patients who have already had a recent stroke or TIA.
If you don’t have noticeable symptoms of carotid artery stenosis, there are a few ways you might find out you have it. First, your primary care physician or general cardiologist may come to suspect you have plaque in your carotid artery through a physical exam. They may consider your risks, like a family history of the disease. Your PCP can also listen to blood flow in your neck with a stethoscope and hear signs of abnormalities. From there, they would order further imaging tests, such as carotid ultrasound, to find out whether the artery is narrowed.
Rush also offers a heart CT scan that can detect plaque in the arteries. No referral is needed for this test, and the results can help your doctor find out whether you should have further tests or treatment.
Carotid endarterectomy is highly effective for preventing stroke in patients with high-grade carotid artery stenosis. Studies have shown long-term benefits even in patients who have not yet had stroke symptoms. It is a durable procedure that completely removes plaque from the carotid artery.
Complications from carotid endarterectomy are uncommon. When they happen, they usually appear within the first 24 hours after surgery, which is why patients remain under observation and their blood pressure is monitored during that time. There is a risk of bleeding or bruising at the site of surgery, and some patients feel hoarse and have difficulty speaking, chewing or swallowing. There is also a small risk of stroke in about 1% or fewer patients. Some patients may also have headaches, called reperfusion injury. This happens when the brain has become used to getting less blood flow. When the artery is suddenly open following surgery, the brain’s blood vessels react by spasming, causing headaches. This usually happens in patients with a history of stroke, high-grade stenosis, uncontrolled blood pressure or carotid artery blockage on the other side of the neck. These patients may need blood pressure medication and frequent follow-ups. In severe cases, they may need emergency treatment.
Most patients go home to recover from carotid endarterectomy the day after the procedure. They are often prescribed medication for pain, but most only need to take it for a day or two. While recovering at home, patients are advised to avoid a lot of movement and not put pressure around the area of the suture. Usually after about two weeks, they can slowly start physical activity again, such as going for walks or climbing stairs.
Carotid artery stenting involves placing a stent via a catheter, usually inserted through the groin or the neck. The stent is then inflated within the carotid artery. It pushes plaque away to open the artery, contain the plaque and restore blood flow. This minimally invasive procedure is performed under local anesthesia. The goal is the same as it is with carotid endarterectomy — to prevent a stroke.
Carotid endarterectomy differs in that it is an open surgery that completely removes plaque from the carotid artery, rather than pushing it away or containing it with a stent. Sometimes stenting doesn’t open the artery enough and requires further surgery to remove the stent and clear the plaque, though that is very rare.
But there are situations where stenting may be a more appropriate option— for example, if you have severe heart and/or lung disease, aren’t a good candidate for general anesthesia, have had previous radiation treatment or had prior surgery in the neck. Your surgeon can discuss all your options with you.
Carotid endarterectomy is usually covered by insurance. But it’s best to ask your insurance provider about which procedures, locations and physicians are covered under your plan. You can also find answers to basic insurance questions on our Insurance page.
In the weeks leading up to the procedure, it is important to manage your risks and your blood pressure. This may include reducing your cholesterol with medications and dietary changes, getting diabetes under control, quitting smoking and maintaining an exercise routine. Unlike many other procedures, your surgeon will advise that you continue using any recommended blood thinners, such as aspirin, until the day of surgery.
On the day before your procedure, do not eat or drink anything after midnight. If you need to take medications on the day of your surgery, do so in the morning with only small sips of water. Your surgeon will work with your anesthesia team to advise you further on anything else you may need to do.
