carotid endarterectomy

Alternative Names 
CEA

Definition
Carotid endarterectomy (CEA) is a procedure used to remove a blockage in the carotid artery to prevent a stroke from occurring. The carotid arteries are blood vessels located in the neck that supply blood to the brain. There is one carotid artery on each side of the neck. When these vessels become narrowed or blocked, blood flow to the brain is reduced. This can lead to a stroke.

Who is a candidate for the procedure? 
Many people develop fatty deposits on the insides of their arteries as they grow older. This is known as arteriosclerosis. If the deposits become too big in the carotid arteries, people are at risk for a stroke. Those who have a high degree of blockage in the carotid arteries are at the highest risk for a stroke. These are the people who benefit from a carotid endarterectomy.

People with lower amounts of blockage are only offered a carotid endarterectomy under special circumstances. For example, if a person is having symptoms from a blocked artery even though the blockage is only moderate, he or she may be a candidate for this procedure. Symptoms of a blocked carotid artery may include temporary muscle weakness on one side of the body,speech difficulties or blindness.

Surgery is offered to possible candidates only after special evaluation is done with various X-ray tests to determine the amount of blockage a person has. The surgeon then discusses the risks and benefits of surgery. The benefit of CEA is that the chance of having a stroke in the future is reduced. Strokes can cause death or permanent disability, such as the inability to talk or move. People who are candidates for this surgery must then decide whether or not they want to have the operation.

How is the procedure performed? 
A carotid endarterectomy is usually done in the hospital using general anaesthesia. With general anaesthesia, the person is put to sleep completely with medications. Occasionally, the surgeon will prefer to use local anaesthesia. This means the area where the incision will be made is injected with medications to numb it, but the person stays awake. The choice of anaesthesia will be discussed by the surgeon and anaesthetist before the surgery. An anaesthetist is a doctor who specialises in pain control during surgery.

To begin the surgery, a cut is made into the neck. The muscle layer beneath the skin is opened, and the carotid artery is separated from the surrounding tissue. The artery must be empty before the surgeon can operate on it. To accomplish this, the artery is clamped with special tools to prevent blood flow. The person is given a medication called heparin to thin the blood and prevent blood clots from forming.

Some surgeons prefer to use a shunt to maintain blood flow to the brain. This is a small tube that is inserted above and below the area of blockage in the artery before it is clamped. A shunt allows blood to flow around the blockage during the surgery.

Once blood flow is controlled, the artery is cut open. The blockage is cut out and removed. This leaves a smooth inner layer to the artery. The artery is then sewed shut. Sometimes the artery is patched with a vein or a piece of synthetic material. A special tube, known as a drain, may be placed in the incision to drain any extra blood that collects. The openings in the neck muscles and skin are then sewn shut, and the wound is bandaged.

What happens right after the procedure? 
After the surgery, the person will be taken to the surgery recovery room to be watched closely for a short time. Blood pressure, pulse, breathing, and awareness will be checked often. The person will also be checked for any signs of bleeding. The person will need to stay in the hospital for a day or 2 after the surgery and is allowed to eat normally and move around once he or she is stable.

What happens later at home? 
Most people will have a sore neck where the muscles were cut for a few weeks. This usually can be relieved with heat and analgesia. Most people function well after returning home. The surgeon provides specific wound care instructions before sending the person home.

What are the potential complications after the procedure? 
Complications from a carotid endarterectomy vary from mild to major. Some people have muscle tenderness and mild bleeding. Also, a person may have bruising or bleeding into the neck tissues from the use of the blood-thinning medication. This is usually not serious and goes away by itself.

Occasionally, there may be nerve damage to 1 of the nerves in the neck or face, which may cause permanent muscle weakness. About 3% of the people who have a carotid endarterectomy will have a stroke around the time of the surgery. This risk is higher among people who were having symptoms before surgery. Infection and allergic reactions to anaesthesia may occur. Intracerebral haemorrhage, or bleeding in the brain, is an infrequent but serious complication. Rarely, the person may have a heart attack or even die after an endarterectomy.

Author: Michael Peetz, MD
Reviewer: eknowhow Medical Review Panel
Editor: Dr John Hearne

Last Updated: 1/09/2004
Contributors
Potential conflict of interest information for reviewers available on request