Carotid endarterectomy
Carotid endarterectomy is surgery to remove plaque buildup in the carotid arteries. During a carotid endarterectomy:A small incision is made in the neck just below the level of the jaw. The narrowed carotid artery is exposed. The blood flow through the narrowed area may be temporarily rerouted (shunted). Rerouting is done by placing a tube in the vessel above and below the narrowing. Blood flows around the narrowed area during the surgery. The artery is opened and the plaque is carefully removed, often in one piece. A vein from the leg may be sewn (grafted) on the carotid artery to widen or repair the vessel.
Carotid endarterectomy (CEA) is a surgical procedure used to prevent stroke, by correcting stenosis in the common carotid artery. Endarterectomy is the removal of material on the inside of an artery.
Atherosclerosis causes plaque to form in the carotid arteries, usually at the fork where the common carotid artery divides into the internal and external carotid artery. The plaque can build up in the inner surface of the artery (lumen), and narrow or constrict the artery. Pieces of the plaque, called emboli, can break off (i. e. embolize) and travel up the internal carotid artery to the brain, where it blocks circulation, and can cause death of the brain tissue.
Sometimes the plaque causes symptoms first. The symptoms are temporary or transitory strokes, known as transient ischemic attacks (TIAs). By definition, TIAs last less than 24 hours; after 24 hours they are called strokes. Symptomatic stenosis has a high risk of stroke within the next 2 days. National Institute for Health and Clinical Excellence (NICE) guidelines recommend that patients with moderate to severe (50-99% blockage) stenosis, and symptoms, should have “urgent” endarterectomy within 2 weeks.
When the plaque doesn’t cause symptoms, patients are still at higher risk of stroke than the general population, but not as high as patients
with symptomatic stenosis. The incidence of stroke, including fatal stroke, is 1-2% per year. The surgical mortality of endarterectomy ranges from 1-2% to as much as 10%. Two large randomized clinical trials have demonstrated that carotid surgery done with a 30 day stroke and death risk of 3% or less will benefit asymptomatic patients with ≥60% stenosis who are expected to live at least 5 years after surgery. Surgeons are divided over whether asymptomatic patients should be treated with medication alone or should have surgery.
In endarterectomy, the surgeon opens the artery and removes the plaque. A newer procedure, endovascular angioplasty and stenting, threads a catheter up from the groin, around the aortic arch, and up the carotid artery. The catheter uses a balloon to expand the artery, and inserts a stent to hold the artery open. In several clinical trials, the 30-day incidence of heart attack, stroke, or death was significantly higher with stenting than with endarterectomy (9.6% vs. 3.9%) The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) funded by the National Institutes of Health (NIH) reported that the results of stents and endarterectomy were comparable. However, the European International Carotid Stenting Study (ICSS) found that stents had almost double the rate of complications.
Procedure
The internal, common and external carotid arteries are clamped, the lumen of the internal carotid artery is opened, and the atheromatous plaque substance removed. The artery is closed, hemostasis achieved, and the overlying layers closed.
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