Carotid Endarterectomy

Definition

Carotid endarterectomy is a surgical procedure in which a stenosis (narrowing) or ulceration of an atherosclerotic plaque in the carotid artery is removed.

Description

When atherosclerosis has narrowed the carotid artery (one of the arteries supplying blood to the brain), carotid endarterectomy may reduce the risk of stroke. It has been used in patients with Transient Ischemic Attacks (TIAs), in those who have had a stroke, or in those who are at high risk for stroke. A TIA may produce symptoms such as weakness or sensory changes on one side of your body, speech alterations, and/or visual disturbances. Episodes usually last for only a few minutes but may continue for up to 24 hours.

The carotid arteries are two of the three main vessels supplying blood to the brain. During the operation, the surgeon opens the carotid artery in the neck and removes blood clots or other material obstructing the flow of blood from the artery.

Based on current knowledge, carotid endarterectomy plus optimal medical treatment is highly effective in preventing stroke and death in symptomatic patients with carotid stenoses greater than 70 percent. However, it is essential that the vascular surgeon be one with a mortality-complication rate of less than 5 percent.

Potential Risk

Carotid endarterectomies in asymptomatic patients are controversial because of a notorious tradeoff. You can risk a stroke or death by foregoing the operation. Or you can risk heart attack, stroke, or death during surgery.

About 2 percent of patients per year with asymptomatic carotid stenoses suffer a stroke. If the stenosis exceeds 75 percent of the lumen (inner area) of the artery, the figure increases to about 3 percent of patients. Thus, the risk of stroke from angiography (using dye to evaluate the carotid arteries) and surgery together should be less than 3 percent, or the risks may outweigh the benefits.

The American Heart Association has recommended upper limits of acceptable combined morbidity and mortality for carotid endarterectomy. These are 3 percent for asymptomatic patients and 5 percent for those with TIAs or stroke. These figures are 7 percent in patients with previous stroke and 10 percent in individuals with recurrent carotid stenoses.

Do You Need the Surgery?

Some physicians suggest that the patients who benefit the most from this operation are those whose carotid artery is blocked more than 70 percent. According to a study in Lancet in 1991, strokes in such cases can be reduced six-fold. With less than 30 percent of the artery blocked, the risks definitely outweighed the benefits. Between these two extremes the results were inconclusive.

Another study, by the National Institutes of Health in 1991, found that in patients with a 70 to 90 percent narrowing of the carotid artery, surgery reduced the likelihood of stroke from more than 25 percent to less than 10 percent. In the 18 months after surgery, 24 percent of the patients treated medically, but only 7 percent of the surgical patients had a stroke on same side as the narrowed artery. During that same period, 12 percent of the medical patients, compared to 5 percent of the surgical patients, had a major or fatal stroke or died of any cause.

In 1995, a trial was reported comparing carotid endarterectomy with aspirin in patients with asymptomatic carotid stenosis exceeding 60 percent. Patients enrolled were under 80 years of age and were considered good surgical candidates.

Although there was an early morbidity and mortality disadvantage in the surgical group, projected 5 year data in these patients were considerably more favorable than those of the aspirin group. Although still controversial, the procedure may be offered to selected asymptomatic patients who are good surgical risks.

For an expert opinion, consult either a vascular surgeon or a neurosurgeon.

Questions to Ask Your Doctor

What tests need to be done to diagnose the condition? To determine if surgery is necessary?

Should a specialist be consulted?

Are there any alternative treatments to improve the blood supply without surgery?

If no surgery is performed, what is likely to happen?

How many endarterectomies have you performed?

What is your complications rate?

What are the risks of this surgery?

How is the surgery done?

What can be expected after surgery?