Patient Information on Open surgery on the Carotid Arteries – Carotid Endarterectomy

Who is this leaflet for and what is its aim?

This leaflet is for patients who have been diagnosed with carotid stenosis and have been recommended to have open carotid artery surgery with a carotid endarterectomy.

This leaflet aims to explain the procedure and its risks.

Background information

Carotid endarterectomy is an operation to treat a narrowed artery in the neck (the carotid artery), which supplies blood to the brain. The narrowing is caused by a build up of fatty material within the artery wall – a plaque. During the operation this is removed, thus clearing out the artery.

Clearing out the artery reduces the risk of strokes by preventing bits of the plaque breaking off and lodging in the brain.

Without surgery, patients with a severe stenosis of the carotid artery have at least an approximate 30% chance (3 in 10) of having a stroke in the next three years.

With surgery, the risks over the same time period are reduced to 10-15% (less than 1 in 15).

The procedure

We make an incision (cut) that runs obliquely (at an angle) along the side of your neck from just below your ear lobe to just below the side of your Adam’s apple.

During the operation, we expose (make visible) the carotid arteries. We will give you heparin to thin your blood. We then temporarily stop the blood flow through the carotid artery and make a cut in the wall of the artery to expose the diseased area.

We then place a specialised piece of plastic tubing (known as a shunt) inside the artery to by-pass the diseased part of the artery and, therefore, restore blood flow to the brain.

We then remove the diseased area inside the artery (this is called endarterectomy).

Then we repair the cut in the wall of the artery using a small bovine pericardial patch, which prevents narrowing after the operation.

At the end of the operation, we remove the plastic shunt tubing and allow the blood to flow again through the repaired artery.

The final stage is to close the wound with self-dissolving stitches.

After the procedure

Once your surgery is completed you will be transferred to our Overnight Intensive Recovery ward – a high dependency ward where you will be looked after by specially trained nurses, under the direction of your anaesthetist, overnight.

The nurse looking after you will make careful measurements of your pulse, blood pressure and breathing. Every few minutes, the nurse will ask you questions to check you are awake and ask you to perform certain tasks, for example ‘squeeze my hand’, ‘stick out your tongue’.

The nurses will monitor you closely until the effects of any general anaesthetic have adequately worn off and you are conscious. You may be given oxygen via a facemask, fluids via your drip and appropriate pain relief until you are comfortable enough to return to your ward.

If there is not a bed in the necessary unit on the day of your operation, your operation may be postponed as it is important that you have the correct level of care after major surgery.

The side of your neck will feel stiff and swollen.

At this time, you might find there is a urinary catheter inserted into your bladder, which allows your urine to drain into a bag. This is a temporary measure to prevent urine becoming retained which can cause your blood pressure to become unstable.

The following day, if all the measurements are fine and you have recovered sufficiently from the anaesthetic, you will be returned to the ward where you will continue to be monitored closely until discharge.

Leaving hospital

Patients usually stay for 1-2 nights after the procedure is completed.

Resuming normal activities including work

You may need 2-4 weeks off work. Please return when you feel comfortable. Avoid driving until you are pain-free and in full control of the vehicle, and able to move your neck sufficiently to look around easily without pain. The Stroke Doctors may have explained the legal requirements from the DVLA for returning to driving.

You may resume sex when it is comfortable, which is usually after 2 weeks.

Special measures after the procedure

After the surgery, your neck will feel a bit swollen. If it becomes more so, or you are concerned, please call the daytime number for the hospital given to you on the information sheet, the Cambridge Vascular Unit Vascular Specialist Nurses, or you can call your GP.

If you experience a persistent headache you should get in contact with the Vascular Specialist Nursing Team.

If there are non-absorbable sutures to remove, information will be given to you for removal with your GP Practice nurse.

Intended benefits

To remove the diseased area from the affected carotid arteries with the aim of reducing the risk of stroke occurring in the future.

Risks

There is a small risk of stroke at the time of operation (approximately 2 to 3%).

To keep this risk as low as possible, we thin the blood using heparin during surgery, and give you aspirin and / or clopidogrel which reduces the ‘stickiness’ of the platelets in the blood.

All major operations carry general risks including problems with the heart. On average there is a 1 to 2% risk of a heart attack following surgery. Often, this is related to problems with unstable blood pressure in the first 24 hours following surgery. For this reason, we monitor your blood pressure very carefully during this period, and give medications to prevent your blood pressure becoming too high or too low. If you experience a headache once at home this might be that

Surgery on the arteries of the neck is very complex not only because the carotid arteries supply blood to the brain but also because there are a number of important nerves that lie near to the carotid arteries.

Permanent damage to these nerves is relatively uncommon (in only 2 to 3% of patients), however, temporary nerve problems are more common. These usually recover completely. This temporary damage to the nerves can result from stretching them slightly to expose the disease in the arteries.

This can affect the nerve to the voice box, which results in a hoarse voice. The nerve to the tongue can be affected resulting in a numb tongue that feels ‘clumsy’. Occasionally, the nerve responsible for swallowing can be affected.

Also, the nerve to the corner of the mouth can be affected causing temporary drooping of the side of the mouth. Most people get some numbness to the skin around the jaw this can take some months to recover and may not recover completely.

Surgery on the carotid arteries always produces bruising and soreness.

Occasionally, blood can collect in the wound in the hours after surgery, which causes the neck to swell and breathing to be difficult: in some patients (less than 5%) this haematoma (blood clot) needs to be removed with further surgery. The wound to the neck is usually red and sore immediately after the operation; however, this should improve in the days after your surgery.

If the wound becomes increasingly red and sore, this might indicate the presence of infection, which requires prompt treatment with antibiotics and assessment by your surgeon.

This risk of wound infection is small (1 to 5% chance). Very occasionally, the patch we use to close the artery can get infected (<1%). If this occurs it may require further surgery to correct.

Added together, with all the possible complications, there is a small risk to life with this procedure.

Alternatives

Medical therapy

An injection can be used to cause scarring and eventual blockage to the faulty

You may be treated medically rather than with surgery. Modern medical therapy is extremely effective and has few side-effects. However, we await trials to provide evidence that medical treatment alone can reduce the risk of stroke in people who have narrowed carotid arteries that have caused a stroke or mini stroke.

Carotid artery stenting

Carotid stenting is a recent treatment that has been developed where an endovascular stent is placed over the carotid stenosis via the groin or the wrist. It has been shown to have a higher rate of stroke after treatment than open surgery, but can be extremely useful and appropriate in the right circumstances to reduce the risk of stroke.

Medication

Bring all of your medicines (including inhalers, injections, creams, eye drops or patches) and a current repeat prescription from your GP

Please tell the ward staff about all of the medicines you use. During your stay If you wish to take your medication yourself (self-medicate) please speak with your nurse. Pharmacists visit the wards regularly and can help with any medicine queries.

MyChart

We would encourage you to sign up for MyChart. This is the electronic patient portal at Cambridge University Hospitals that enables patients to securely access parts of their health record held within the hospital’s electronic patient record system (Epic). It is available via your home computer or mobile device

More information is available on our website: MyChart

Contacts

Do feel free to contact the Cambridge Vascular Unit Specialist Nurses via email or on 01223 348526 if you have any questions or anxieties.

Sources of evidence

• The Vascular Society website (opens in a new tab)
• Circulation Foundation UK website (opens in a new tab)