Our Summary

This paper reviews research on carotid endarterectomy (CEA), a surgical procedure used to prevent stroke by correcting stenosis (narrowing) in the common carotid artery or internal carotid artery. Over the past 60 years, techniques for CEA have evolved and improved. Nowadays, most doctors use a microscope to help them see and remove the plaque that is narrowing the artery.

There are different methods for making the incision in the skin for the surgery. The most common one is a longitudinal incision (an up-down cut), but a transverse incision (a left-right cut) is less invasive and leaves a nicer scar.

Different techniques are also used to monitor the patient during surgery, but no single technique has been proven to be the best. The use of multiple monitors seems to be better for predicting any neurological problems after the surgery.

It’s still unclear whether it’s better to always use a shunt (a tube that can help maintain blood flow during the operation) or only use it when necessary. This decision is usually left to the individual surgeon.

There are also various techniques to manage the blood flow in the internal carotid artery when the plaque is high up in the neck or when the artery splits into two. Minimally invasive techniques are preferred.

Research has shown that patch angioplasty (sewing a patch onto the opened artery to prevent it from narrowing again) can reduce the risk of stroke and the artery narrowing again. However, few surgeons in Japan are using this technique.

Training programs and realistic training models are needed because most surgeons in Japan do not perform many of these operations.

FAQs

  1. What is the most common type of incision used in carotid endarterectomy?
  2. What is the role of monitoring during carotid endarterectomy and how does it help in predicting postoperative neurological deficit?
  3. What are the benefits of patch angioplasty in carotid endarterectomy and why is it not commonly performed in Japan?

Doctor’s Tip

One helpful tip a doctor might tell a patient about carotid endarterectomy is to make sure to follow all post-operative care instructions carefully. This may include taking prescribed medications, attending follow-up appointments, and avoiding activities that could put strain on the neck. By following these instructions, the patient can help ensure a successful recovery and reduce the risk of complications.

Suitable For

Carotid endarterectomy (CEA) is typically recommended for patients with carotid artery stenosis, especially those with symptomatic severe stenosis (greater than 70%) or asymptomatic moderate to severe stenosis (greater than 60%). Patients who have had a transient ischemic attack (TIA) or stroke related to carotid artery disease are often considered good candidates for CEA to prevent future cerebrovascular events. Additionally, patients with high cervical carotid bifurcation or high plaque may require specialized surgical techniques for successful CEA. Monitoring during the procedure and the use of shunts may also be recommended based on individual patient characteristics and surgical preferences. Patch angioplasty is often used to reduce the risks of stroke and restenosis following CEA. Surgeons should consider the latest literature and techniques to provide optimal care for patients undergoing CEA.

Timeline

  • Before carotid endarterectomy (CEA):
  1. Patient is diagnosed with carotid artery disease through imaging tests such as ultrasound, CT scan, or MRI.
  2. Patient may undergo medical therapy to manage symptoms and prevent further progression of the disease.
  3. Surgeon evaluates the patient’s overall health and determines if they are a suitable candidate for CEA.
  4. Pre-operative tests and evaluations are conducted to assess the patient’s risk factors and plan for the surgery.
  • During carotid endarterectomy (CEA):
  1. Patient is placed under general anesthesia.
  2. Surgeon makes an incision in the neck to access the carotid artery.
  3. Artery is opened, plaque is removed, and the artery is repaired.
  4. Monitoring devices may be used to assess blood flow and neurological function during the procedure.
  5. Shunt may be placed to maintain blood flow to the brain during surgery.
  6. Closure of the incision is performed, and the patient is moved to recovery.
  • After carotid endarterectomy (CEA):
  1. Patient is monitored in the hospital for any complications or signs of stroke.
  2. Medications may be prescribed to prevent blood clots and manage pain.
  3. Patient may undergo follow-up imaging tests to assess the success of the surgery and monitor for restenosis.
  4. Rehabilitation and lifestyle changes may be recommended to reduce the risk of future strokes.
  5. Long-term follow-up with the surgeon and healthcare team is important to monitor the patient’s overall health and the status of the carotid artery.

What to Ask Your Doctor

  1. What are the risks and benefits of carotid endarterectomy for my specific condition?
  2. What type of incision will be used for the surgery, and what are the advantages and disadvantages of each type?
  3. Will I need to have a shunt placed during the surgery, and if so, why?
  4. What monitoring techniques will be used during the surgery to ensure my safety?
  5. How will distal control of the internal carotid artery be achieved during the surgery?
  6. Will patch angioplasty be used to reduce the risks of stroke and restenosis, and why or why not?
  7. How many carotid endarterectomy procedures do you perform each year, and what is your success rate?
  8. Are there any alternative treatments or procedures that I should consider for my condition?
  9. What is the recovery process like after carotid endarterectomy, and what should I expect in terms of postoperative care and follow-up appointments?
  10. Are there any specific lifestyle changes or medications that I should consider after the surgery to prevent further complications?

Reference

Authors: Uno M, Takai H, Yagi K, Matsubara S. Journal: Neurol Med Chir (Tokyo). 2020 Sep 15;60(9):419-428. doi: 10.2176/nmc.ra.2020-0111. Epub 2020 Aug 15. PMID: 32801277